*Purpose: Obstructive sleep apnea (OSA) is known to have deleterious effects on health and survival among the general population and patients with chronic kidney disease. There is limited information about the effects of OSA in kidney transplant recipients.

*Methods: We analyzed data from kidney transplant recipients transplanted at our university hospital between 1994 and 2014. Outcomes of death, death-censored graft failure (DC-GF) and rejection were compared between those with pre-transplant OSA, post-transplant OSA and those who without an OSA diagnosis.

*Results: There were 366 patients with pre-transplant OSA (pre-OSA+) and 4388 without (pre-OSA-). Those with pre-OSA+ were more likely to be male (83% vs. 58%; p=<0.01), were older at time of transplant (55 ± 11 vs 48 ± 14 years; p=<0.01) and had higher body mass index (31.6 ± 4.8 vs 26.7 ± 5.3 kg/m²;p <0.01) than pre-OSA-. The unadjusted hazard ratio (HR) for death was significantly higher in the pre-OSA+ group (HR=1.42; 95% CI, 1.09-1.85, p <0.01). There was no significant difference for DC-GF or rejection. After adjustment for multiple factors (age, sex, race, types of transplant, the cause of ESRD, prior transplant, BMI, years of transplant, delayed graft function), there was no significant difference in risk for any of the three outcomes. Results were similar in analyses stratified by self-reported compliance for OSA treatment.

We also compared 182 recipients who developed OSA post-transplant (Post-OSA+) to 4206 recipients who did not (Post-OSA-). Those Post-OSA+ had a higher risk of death in unadjusted analyses (HR=1.68, 95% CI: 1.22-2.31, p <0.01), but not after adjustment. DC-GF was significantly lower in Post-OSA+ group (HR=0.64; CI, 0.43-0.96, P <0.05) after adjustment for multiple factors.

*Conclusions: OSA did not have direct deleterious effects in this unique population following kidney transplantation. This could be due to the presence of other multiple co-morbidities and complications that lead to early death. Compliance with the OSA treatment was self-reported and may have affected the outcomes. As our understanding and management of various complications are evolving, further research is needed to understand the relationship between OSA and any complications in kidney transplant recipients.

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