*Purpose: Kidneys with a high Kidney Donor Profile Index (KDPI, 80-100%) are frequently declined as they are associated with higher graft loss; yet, candidates that decline must wait for a future offer that may never come. We sought to characterize outcomes of candidates who declined a high KDPI kidney.

*Methods: We used SRTR data from 2009-2018 to study 149,976 candidates who were offered a high KDPI kidney. We used competing risks regression to characterize the natural history of those who declined, and used adjusted Cox regression to compare the post-decision survival of decliners versus acceptors of high KDPI offers. We used an interaction term to determine whether the survival benefit of acceptance varied across KDPI.

*Results: Among candidates who declined high KDPI kidneys, 45.0% were eventually transplanted, 21.1% died, 20.1% were removed from the waitlist, and 13.6% remained waitlisted (Figure 1). Despite this substantial mortality risk, the survival benefit depended on the KDPI range of the accepted kidney. Acceptors of KDPI 80-95% kidneys experienced a 27% survival benefit compared to decliners (adjusted hazard ratio [aHR]: _0.690.73_0.77, p<0.001; absolute 5-year risk 18.7% vs. 27.2%) (Figure 2). Moreover, the survival benefit was comparable between KDPI 80-95% (p for interaction >0.05). Conversely, acceptors of KDPI 96-100% experienced a 17% survival benefit compared to decliners (aHR: _0.770.83_0.89, p<0.001; absolute 5-year risk 22.2% vs. 27.4%) (Figure 3).

*Conclusions: Acceptors of high KDPI kidneys derived a survival benefit, with greater benefit for KDPI 80-95% acceptors. Appropriate selection of high KDPI kidneys may reduce wait-times and improve survival.

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