In the United States, presently there are more than 50,000 patients with end-stage renal disease (ESRD) awaiting a cadaveric kidney and each year less than a quarter receive kidney transplantation. Although the real incidence in unknown, a significant number of these patients die due to lack of dialysis access. While various medical necessities are indications for emergent transplantation of other organs, the current kidney allocation system of the United Network for Organ Sharing (UNOS) makes no room for those ESRD patients whose death is imminent due to lack of vascular access. Local organ procurement organizations (OPOs) are allowed to make decisions based on arbitrary policies (or no policies at all) which often falter and fail to deal appropriately with a largely ignored issue. The growing wait for cadaveric kidneys makes the problem of ESRD patients dying due to lack of dialysis access increasingly important and one that must be addressed through a revision of the UNOS kidney allocation system.