*Purpose: Among recipients of high kidney donor profile index (KDPI) kidneys, it is unclear if certain recipients fair better than others. Using data from the Scientific Registry of Transplant Recipients (SRTR), we aimed to 1) identify recipient characteristics most suitable for a high KDPI kidney and 2) identify factors that can be potentially targeted pre-transplant to improve allograft and patient outcomes post-transplant.

*Methods: We included adult, first-time, kidney only transplant recipients transplanted between 12/14-03/20. Using a multivariable Cox model, we identified recipient characteristics that were associated with allograft survival. We then selected recipients >50 years old, and categorised patients into 8 groups based on three predictive variables determined by the Cox model: diabetes (yes/no), on dialysis (yes/no) and obesity (BMI<30 or >30). We compared allograft and patient survival of high KDPI kidney recipients.

*Results: Table 1 depicts the baseline characteristics of all recipients. Obese diabetic recipients who were on dialysis at the time of transplant had a significantly higher risk of allograft failure [1.46 (1.08, 1.97); p=0.01] than the reference group (no dialysis, non-diabetic, non-obese). All other groups had allograft survival comparable to the reference group. Diabetic patients who were on dialysis had the worst patient survival regardless of their BMI [1.55 (1.05, 2.27); p=0.03 for BMI<30; 2.02 (1.38, 2.97); p=<0.01 for BMI>30]. (Table 2)

*Conclusions: Amongst high KDPI kidney recipients, the combination of diabetes and being on dialysis predicts poor patient and allograft outcomes, with obese patients having worse outcome compared to non-obese patients. Elderly diabetic patients may benefit greatest from weight reduction and early referral for preemptive kidney transplant should they choose to receive a high KDPI kidney.

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