The Kidney Donor Profile Index (KDPI) was recently introduced as a metric for quality of DD kidneys. The survival benefit of transplantation with high-KDPI kidneys (high-KDPI KT) is unknown.

This retrospective cohort study of waitlist patients from 2002-2011 compared outcomes after high-KDPI KT to standard treatment (remaining on the waitlist or transplant with a lower-KDPI kidney) using time-dependent Cox regression, adjusting for transplant candidate characteristics. Outcomes were time-varying mortality hazard (time to equal risk) and cumulative mortality (time to equal survival).

Mortality risk increased in the first 30 days after high-KDPI KT, then decreased, becoming statistically significantly lower than standard treatment after 30 days (KDPI 71-80)/180 days (KDPI 81-90 and 91-100). Long-term (>3-year) mortality risk was lower after high-KDPI KT; the difference was statistically significant for KDPI 71-80 (HR=_0.70 0.78 _0.86, p<=.001) but not for KDPI 81-90 (HR=_0.82 0.91 _1.01, p=0.1) or KDPI 91-100 (HR=_0.86 0.96 _1.08, p=0.5).

Greater reduction in long-term mortality risk was observed in centers with longer median wait times. Risk reduction was independent of recipient characteristics.

Time to equal survival was 7.9 months post-transpant for KDPI 71-80, 17.7 months post-transplant for KDPI 81-90, and 20.2 months post-transplant for KDPI 91-100. Past these times, high-KDPI KT conferred a net survival advantage.

High-KDPI KT confers net long-term survival advantage due to decreased mortality in the period 0.5-3 years post-transplant. The benefit is greatest at centers with longer wait times.

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