*Purpose: To evaluate predictors of long-term graft function and unfavorable outcomes in living-donor preemptive kidney transplant recipients.

*Methods: A single-center cohort study enrolled 223 living-donor preemptive kidney transplant recipients transplanted between 2011 and 2016 and followed up to 2021. Five-year graft function was estimated by CKD-Epi (5-year-eGFR). The primary outcome was composed of death, graft loss, acute rejection, and 5-year-eGFR < 30 mL/min/1.73m2. The multivariable analysis for 5-year-eGFR was performed by linear regression and the primary outcome by logistic regression. AUC-ROC evaluated the performance for predicting primary outcome. Kaplan-Meier estimated graft survival.

*Results: The overall incidence of acute rejection, graft loss, and death was 19.4%, 6.3%, and 0.5%, respectively. The median follow-up time was 88.9 months, and the median 5-year-eGFR was 54.7 mL/min. In the linear regression, the association with 5-yr-eGFR was less evident with HLA matches than donor age. Thus, the identical HLA match tends to be associated with 5-year-eGFR in the linear regression (B= +5.95; P=0.09), while donor age (B= -0,70 per year old; P<0.001) and acute rejection (B= -7.17; P=0.04) presented a significant and inverse association. Sixty-three patients presented the primary outcome (28.2%), which was significantly associated with CMV-related events (OR=4.09; P=0.001) and HLA compatibility. Compared to identical HLA matches, the OR was 6.95 for haploidentical (P=0.001) and 10.2 for distinct (P<0.001) HLA matches. The risk of primary outcome was reduced by 77% in patients who received thymoglobulin as induction therapy. This model achieved an AUC-ROC of 0.75 (CI95%= 0.68-0.82; P<0.001). Five-year graft survival was 94.5%.

*Conclusions: In recipients of living-donor preemptive kidney transplants, donor age and acute rejection were predictors of long-term graft function, but the association with HLA matches was less evident. In addition, the HLA matches, thymoglobulin induction therapy, and CMV-related events were predictors of composite outcomes of long-term death, graft loss, acute rejection, and low grade of graft function.

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