*Purpose: This study explores patient and physician perspectives on patients’ understandings of kidney quality and patients’ decision making with regards to consenting for and accepting KDPI>85 kidney offers.

*Methods: In-depth,, semi-structured interviews were conducted with transplant candidates (15), transplant recipients (16), transplant surgeons (9) and transplant nephrologists (6). Patients were recruited through the American Association of Kidney Patients (AAKP) and the Northwestern Comprehensive Transplant Center. Physicians were recruited from OPTN committees and a list of transplant center medical directors. Patient interviews focused on education received at their transplant center, understandings of kidney quality and KDPI, and informed consent and kidney acceptance decision making. Physician interviews focused on how they educate patients about kidney quality and which patients they encourage to consent for KDPI>85 kidneys offers. Study team members identified emergent patters within the data, and generated themes following these patterns.

*Results: Five themes emerged from the interviews. First, patients reported knowledge gaps and misperceptions about KDPI. Second, patients and physicians indicated limits to shared decision making with regards to KDPI>85 consent. Third, patients considered experiences on dialysis, health status and age in their KDPI>85 consent and acceptance decisions, while physicians reported significant variation in terms of which patients they encourage to consent for KDPI>85 offers. Fourth, patients frequently expressed concerns about infectious disease, although physicians consistently reported encouraging patients to accept PHS increased risk offers. Finally, patients underestimated the survival benefit of transplantation over dialysis, and physicians suggested that patients may misunderstand the relative risks when making consent and acceptance decisions.

*Conclusions: Patient consent and acceptance decisions are influenced by the education they receive and their understandings of the tradeoff between accepting a lower quality kidney or remaining on the waiting list. Patients express willingness to accept lower quality kidneys if they offer a benefit in terms of survival and/or quality of life, but they do not always have a good understanding of options such as KDPI>85 consent. More comprehensive education is needed to ensure patients have the resources to make informed consent and acceptance decisions.

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