*Purpose: The new kidney allocation system (KAS) instituted in 2014 allowed organ procurement organizations to allocate A2/A2B to B candidates preferentially was meant to improve organ access and reduce wait time for minorities. We previously showed comparable short-term outcomes between A2/A2B and B to B kidney transplants. However, there’s little data on long-term outcomes following A2/A2B to B kidney transplants since KAS. The aim of this study is to report our 5-year experience with A2/A2B to B kidney transplants.

*Methods: This retrospective, single-center analysis included all adults who received A2/A2B to B deceased donor kidney transplants from December 2014 to June 2021 compared to B to B recipients. Outcomes included longitudinal kidney function, death-censored graft survival, overall graft survival, and rejection-free graft survival. Data were analyzed using the Kaplan-Meier method and multivariable mixed effects models of longitudinal serum creatinine (SCr) and estimated glomerular filtration rates (eGFR).

*Results: 53 A2/A2B and 114 B to B adult recipients (70% and 61% African American respectively) were included. Median follow up time was 32 months (range 0.2-82). While SCr increased and eGFR declined between post-transplant month 2 and up to year 6 (p<0.001), after adjusting for African American race (p<0.001), there were no differences between the groups’ overall kidney function values (p>0.80) or their temporal trajectories (time by group interaction p>0.11). Death-censored graft survival was lower in A2/A2B to B compared to B recipients (p=0.03, Figure 1), with 5-year point estimates of 68% and 91% respectively. Overall graft survival (Figure 2) and rejection-free graft survival did not differ between A2/A2B and B recipients (p>0.37).

*Conclusions: A2/A2B to B kidney transplants have lower long-term death-censored allograft survival but comparable overall graft survival, rejection-free survival, and longitudinal renal function compared to B to B transplants at our center. To our knowledge this the first study to report long-term outcomes in this group since KAS.

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