*Purpose: The initial experience with the kidney allocation system (KAS) resulted in an alarming decrease in the number of transplants in our small and isolated center. We hypothesized listing and transplanting older candidates and accepting more marginal kidneys would increase transplants without compromising outcomes.

*Methods: 10-year waitlist additions and deceased donor kidney transplants were retrospectively analyzed 5 years pre-KAS (1/1/10-12/3/14) and 5 years post-KAS (12/4/14-10/31/19). The first 3 years of post-KAS was then compared to year 4-5. X², Fisher’s exact test, t-test, K-M estimate were used for statistical analysis.

*Results:

After the KAS, significantly more 65+ year old and more obese patients were listed. Transplant numbers increased with significantly more older recipients, and with more imported, KDPI 85+, high risk, HCV+ kidney donors. Kidneys were pumped more often, and ischemia times were longer leading to more DGF. These changes were accentuated 3 years after the KAS when significantly even more KDPI 85+ donors, due mostly to more HCV+, and more pre-emptive transplants were performed; there were also increased donor imports and pumped kidneys. There was no difference in graft and patient survival.

*Conclusions: Listing and transplanting older recipients and accepting more marginal kidneys significantly increased number of transplants without compromising patient and graft survival.

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