*Purpose: Whether anatomic findings such as aortic and arterial renal plaque affect kidney graft outcomes is not well defined. Other than anatomical damage, it is unclear whether anatomy features should influence organ offer acceptance decisions. As part of a broader study on Biopsy, Anatomy, and Resistance Effects on Transplant Outcomes (BARETO), we aim to characterize the association between renal plaque on long-term kidney graft survival to help inform decision making.

*Methods: Data were manually entered for a preliminary cohort of 4,475 ECD donor single kidney transplants from 2008-2011. Degree of aortic (hard=2, soft=1, none=0) and arterial (hard=2, soft=1, none=0) renal plaque were added to create a new, composite plaque score (0-4). Kaplan-Meier graft survival analysis out to 10 years was stratified by composite plaque score. Causal inference was performed using doubly robust regression (DRR) to adjust for 17 potential confounders.

*Results: Kaplan-Meier survival analysis revealed a significant (p=0.003) association between plaque score and graft survival probability, with a plaque score of 0 associated with higher graft survival probability and a plaque score of 4 associated with lower graft survival probability (Figure 1). In the unadjusted model, a plaque score of 4 (vs. 0) was associated with significant risk of graft failure (HR: 1.29, 95% confidence interval (CI): 1.11-1.50); this effect attenuated somewhat (HR 1.15, CI: 0.98-1.36) with DRR (Fig 2). A dose-response relationship appears to be emerging based on initial data.

*Conclusions: This new, composite renal plaque score is associated with long-term graft survival outcomes. Specifically, the presence of hard aortic and/or arterial plaque is associated with worse long-term graft survival. Findings from our ongoing study can help inform transplant decision making, including by their incorporation into multivariable graft survival models that summarize organ quality.

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