*Purpose: In addition to immunological complications, non-immunological events should be considered following kidney transplantation. Among them, diarrhea is the most common gastrointestinal complication, but its effect on transplant outcomes remains unclear.

*Methods: This retrospective study enrolled patients who underwent kidney transplantation between May 1993 and December 2017, and reviewed medical records of their hospitalization after transplantation. Patients with diarrhea as chief complaint at admission were defined as diarrhea group. Transplant outcomes, including graft failure and patients’ survival, were compared between patients with diarrhea and those without diarrhea after adjustment of multiple variables.

*Results: Among a total of 1704 kidney recipients, severe diarrhea that required hospitalization was identified in 84 (4.9%) patients. The mean age was 44.5 ± 13.1 years and the proportion of female was 38.1%. Patients with diarrhea showed higher risks of graft failure and all-cause mortality than did patients without diarrhea (adjusted hazard ratio(HR) 4.48; 95% CI 2..84-7.08; P<0.0001, adjusted HR 6.45; 95% CI 3.68-11.31; P<0.0001, respectively). However, risks of rejection, interstitial fibrosis and tubular atrophy, and calcineurin inhibitor-induced nephrotoxicity were not different between the two groups. When diarrhea was divided according to etiology, pathogen identified infectious diarrhea (n=20) showed elevated HR with graft failure than non-infectious diarrhea (n=64), but there was no statistical significance (HR 1.91; 95% CI 0.76-4.77; P=0.168). The development of AKI in association with diarrhea was not associated with graft failure. However, regarding the recovery of AKI, non-recovered patients had a higher risk of graft failure (HR 7.06; 95% CI 1.63-30.56; P = 0.009) than fully recovered patients.

*Conclusions: Diarrhea, which is a non-immunological complication, should be monitored after kidney transplantation to improve transplant outcomes.

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