*Purpose: In the United States (US), kidney paired donation (KPD) networks have facilitated an increasing proportion of KTs annually, but longer-term transplant outcomes and differences in the mortality and graft failure risk between NKR and control living donor KT (LDKT) recipients have not been well described.

*Methods: Using the National Kidney Registry (NKR), the largest US KPD clearinghouse, and SRTR, we compared NKR (N=2,363) recipients to all non-NKR LDKT recipients (N=54,496) (2/2008-12/2017). We estimated the risk of death-censored graft failure (DCGF) and mortality using inverse probability of treatment weighted Cox regression.

*Results: NKR recipients were more likely to be female, African-American, older, on public insurance, have PRA>80, spend longer on dialysis, and be previous transplant recipients (all p<0.001). NKR recipients were followed for a median 3.2 years (max=10.3 years). NKR recipients had similar DCGF (log-rank p=0.2) and mortality (log-rank p=0.6) incidence compared to non-NKR recipients. After adjustment for donor, recipient, and transplant factors, there no detectable difference in DCGF [aHR: 0.99 (0.78-1.24), p=0.9] or mortality [aHR: 0.91 (0.72-1.15), p=0.4] between NKR and non-NKR LDKT recipients.

*Conclusions: Even when transplanting patients with greater risk factors for worse post-transplant outcomes, our KPD results were equivalent to national LDKT controls.

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