Purpose of review In light of the recent changes to the kidney allocation system (KAS) and the observed increase in the rate of transplantation of the highly sensitized kidney transplant candidate, the evaluation and care of this population is a timely topic. Recent findings In its first year, the new KAS has already realized one goal of improving the chances of transplanting the most highly sensitized patients in the waiting list. This has brought to the forefront the need for recipient readiness in this special population, as well as the need for histocompatibility labs and kidney transplant programs to align themselves with each other, and also with the requirements of the United Network for Organ Sharing, and increase proficiency in testing and data interpretation. This manuscript is a review of the literature as well as practice patterns as they relate to the changes in KAS and the observed outcome since the activation of the new KAS, with the ultimate goal of aiding in the development of a more unified approach in the care of this specialized population which will allow for interdisciplinary and cross centre dialogue to optimize long term care and outcomes. Summary Here we will review the changes to the KAS as they affect the highly sensitized kidney transplant recipient, and additional considerations in the evaluation and management of these patients.