*Purpose: Limited health literacy has been associated with a decreased likelihood of listing for transplant and an increased risk of waitlist mortality among kidney transplant candidates. However, little is known about the impact of health literacy on post-transplant outcomes. The objective of this study was to examine the relationship between health literacy and outcomes after kidney transplantation.

*Methods: We assessed health literacy in 691 adults undergoing kidney transplant evaluation at our center between 6/2015 and 3/2017 using the 4-item Brief Health Literacy Screening Tool (BRIEF) as part of a pilot educational intervention. Health literacy was defined as limited if the BRIEF score was ≤ 12, marginal if 13-16, and adequate if ≥ 17. Health literacy was examined using Cox proportional hazards regression, logistic regression, and linear regression modeling.

*Results: During follow-up, 298 adult patients underwent kidney transplant alone at our center. Mean age was 53 ± 14 years, 60% were men, and 78% received living donor kidney transplants. Overall, 25% of the patients (n=74) had limited or marginal health literacy. Limited or marginal health literacy was associated with diabetes and a history of a high school education or less but not with dialysis dependency, donor type, or donor age. No relationship between patient health literacy and post-transplant hospital length of stay, rehospitalizations, or acute rejection was observed. However, marginal patient health literacy was significantly associated with renal allograft failure and death (HR 5.4, CI 1.8-16.1, p=0.003 and HR 7.2, CI 1.7-29.9, p=0.008, respectively). The relationship between marginal health literacy and renal allograft failure and death appeared to be independent of age, gender, or diabetes. Further analysis of the health literacy questions suggest that self-reported need for help with reading materials from doctors or nurses, such as instructions for medicine, was associated with renal allograft failure and with death.

*Conclusions: Limited or marginal health literacy was observed among one quarter of patients receiving kidney transplants at our center. Marginal health literacy, specifically self-reported difficulty reading written materials, appeared to be significantly associated with renal allograft failure and death following kidney transplantation. Efforts to improve post-transplant communication may improve outcomes in kidney transplant recipients with marginal health literacy.

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