We investigated long-term outcomes of spousal donor grafts and factors affecting graft survival in spousal kidney transplantation. Between July 1997 and December 2013, we performed 157 spousal donor renal transplants in our institution. Of those 157 spousal donor, 104 (66.2%) were female and 30 ABO incompatible grafts (19.1%) were included. According to spousal relationship, we divided into 2 groups: Group I: 'wife-to-husband' (n=104, 66.2%), Group II: 'husband-to-wife' (n=53, 33.8%). The clinical characteristics and long-term survival rates were compared with two groups, and risk factors affecting graft survival were assessed. Graft survival rates at 1 year, 5years, and 10 years post-transplantation were 97.1 %, 91.5% and 87.8%, respectively, in the 'wife-to-husband' group, 92.3%, 87.1% and 76.2%, respectively, in the 'husband-to-wife' group. There were no significant differences between the two groups in graft survival (P=0.368).[figure1] The incidence of acute rejection (AR) episodes, surgical complication and infectious complication did not differ significantly. The delayed graft function (DGF) rates were significantly higher in patients with 'husband–to-wife' group (18.9%, P=0.021). The mean serum creatinine levels at 3, 5 and 7 year after KT were significantly lower in the 'husband-to-wife' group, but serum creatinine level at 1 year and 2 years, did not differ significantly (P = 0.164 and 0.572, respectively). From Cox multivariate analysis, AR episode, DGF and Nephron mass index (kidney weight to recipient body weight ratio, Kw/Rw) were independent factors predicting the graft survival (OR 5.94, 4.55, 1.80, respectively). In our study, the graft survival rates between the two groups were not significantly different. Generally, the immunization of wife-recipients to their husband's HLA antigen by pregnancy attributes the higher DGF and AR episode, so it tends to have worse graft survival. However, the Kw/Rw ratio is an important factor of long-term graft survival and graft function. It offsets the immunologic negative factors for graft survivals.

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