*Purpose: The cost of kidney transplantation, in the context of increasing immunological and medical complexity and higher donor and recipient age, remains uncertain. In 2009, the average cost of a kidney transplant performed in Australia was deemed to be $25,850 for DRG reimbursement. We sought to evaluate transplantation costs in contemporary practice.

*Methods: Costs for all kidney transplant admissions between July 2015 and July 2016 in an Australian tertiary transplantation centre were included. All hospital level costs captured by accounting software during the transplant admission were included. Costs were analysed using multivariate linear regression.

*Results: 98 transplants were performed from 34 living and 64 deceased donors, 45 after brain death (DBD) and 19 donation after circulatory death(DCD). Most transplants were immunologically complex: 71 (72%) had ≥2 HLA mismatches, 34 (35%) had pre-transplant donor specific antibodies, 16 (16%) were re-transplants and 7 transplants were ABO incompatible. Delayed graft function occurred in 36 (37%). The age and sex adjusted cost of a transplant admission was $45,313AUD (95%CI: $28,849, $61,778) for DBD transplants, $46,541 (95%CI: $36,583, $56,498) for DCD transplants, and $42,880 (95%CI:$36,664, $51,096) for LD transplants (p=0.7). There was a significant difference between the cost of ABO compatible and ABO incompatible LD transplants at $40,387 (95%CI: 25,331, 55,443) and $63,172 (95%CI: $49,854, $76,491) respectively (p<0.001). Delayed graft function increased the cost of transplant by $15,356 (95%CI: $7953, $22,760, p<0.001) after adjusting for age, sex, donor type, and ABO compatibility. These additional costs were primarily driven by increased length of stay. In our centre, 40% of complex transplants lead to financial losses for the hospital, compared to 27% for standard transplants.

*Conclusions: Immunologically complex transplants and older donors have increased the cost of transplantation. Current funding mechanisms may not take this into account.

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