*Purpose: While the incidence of transplanting a kidney onto atherosclerotic iliac arteries is becoming more common, little is known about the clinical outcome. We performed a systematic review and meta-analysis to investigate patient and graft survival of kidney transplant recipients with aorto-iliac calcification (AIC) compared to recipients without aorto-iliac calcifications (nAIC).

*Methods: We performed a literature search in 5 databases including Embase, Medline, Cochrane, Web of Science and Google Scholar. Articles from January 1^st, 2000 until September 11^th, 2018 were included. The methodology was in accordance with the PRISMA statement. Relevant outcomes for meta-analysis were patient survival, (death-censored) graft survival and delayed graft function. The survival data for meta-analysis was deduced from Kaplan-Meier curves and presented as a pooled risk ratio (RR) using a random effect model. The quality of the evidence was assessed using the GRADE criteria.

*Results: Twenty observational studies were identified from which 8 were eligible for meta-analysis. Short term and long term patient survival were significantly decreased in recipients with AIC (1-year patient survival: RR 2.19, 95% confidence interval (CI) 1.39-3.44, p<0.001, 5-year patient survival: RR 2.47, 95% CI 1.75-3.48, p<0.001). One-year uncensored graft survival was inferior in recipients with AIC (RR 3.15, 95% l (CI) 1.30-7.64, p=0.01). However, 1-year and 3-year death-censored graft survival was similar in recipients with and without AIC (1-year: RR 2.26, 95% CI 0.58-8.82, p=0.24, 3-year: RR 2.19, 95% CI 0.49-9.82, p=0.31). The risk of delayed graft function was not increased in recipients with AIC (RR 1.24, 95% CI 0.98-1.58). Mean 1-year patient survival, uncensored graft survival and death-censored graft survival in recipients who received a kidney transplant on a prosthetic graft was 93.5%, 93.5% and 89.1% respectively. The quality of the evidence was graded as low or very low.

*Conclusions: Patient and uncensored graft survival is significantly inferior in kidney transplant recipients with AIC. Death-censored graft survival is unaffected. The short term results of kidney transplantation on a prosthetic graft seems favorable.

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