*Purpose: Mortality on the kidney transplant waitlist is high especially in candidates with a high Estimated Post Transplant Survival (EPTS) score. We examined outcomes of very high EPTS candidates (>90%) according to transplant type and status.

*Methods: OPTN/UNOS database as of 6/2019 was analyzed for newly listed first-time kidney transplant candidates from a period of 03/27/2014 to 03/29/2019. Individuals listed for multiple organs, at multiple centers, and missing an EPTS were excluded. The EPTS at the time of initial listing was used to define different groups. The outcome of interest was a composite of death or removed from the list as “not fit” for transplant. Survival analysis was used to examine the data.

*Results: A total of 128,266 ESRD candidates waitlisted were examined (48,734, 74,571, and 4961 with EPTS < 30%, 30-90%, and >90%, respectively). Three-year patient survival according to EPTS was 94.3%, 79.9% and 58.1% to an EPTS < 30%, 30-90%, and >90%, respectively (p < 0.001). Of those with an EPTS >90% at initial listing, 3,140 remained in the waitlist, 1,592 received a DDRT and 229 a LDRT with 3-year survival of 41.3%, 83.6%, and 94.3%, respectively (p<0.0001). The > 90% EPTS group that received a DDRT was further stratified according to the KDPI of the organ received (<85%, 85-95%, and >95%). The overall 3-year survival is demonstrated in the graph and table below.

*Conclusions: Mortality of those with EPTS > 90%, who did not receive transplant was very high and half of the patients were no longer a transplant candidate or have died. Among those receiving a transplant, a LDRT conferred the best survival. Outcomes of DDRT were similar regardless of KDPI and was superior to remaining on the waitlist.

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