*Purpose: Healthy older live kidney donor candidates with hypertension may provide an opportunity to increase live kidney donation. However, the impact of this practice on recipient outcomes has not been explored.

*Methods: We studied a US cohort of 20,130 adult LDKT recipients from older (≥50-year-old) live kidney donors between January 2005 and June 2017, including 1440 (7.2%) whose donors had known predonation hypertension. We used inverse-probability exposure weighting to estimate the adjusted long-term all-cause graft loss.

*Results: The median follow-up was 4.7 years (IQR, 2.1-7.7; maximum, 12.5). Survival of recipients from donors with hypertension vs. those without donor hypertension was 96.5% vs. 96.3% at 1 year, 83.2% vs. 84.2% at 5 years, 60.5% vs. 64.1% at 10 years, 50% vs. 53% at 12.5 years. Recipients from older donors with hypertension had similar all-cause graft loss (adjusted hazards ratio _0.951.11_1.28, p=0.18) compared with recipients from older donors without hypertension after accounting for differences in recipient, transplant, and donor factors [Figure].

*Conclusions: Use of older donors with hypertension may increase LDKT with equivalent recipient outcomes compared with receiving an allograft from older donors without hypertension over a median of 4.7 years. These findings may help inform discussion with end-stage renal disease patients considering older donors with hypertension.

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