*Purpose: Although kidney transplantation offers improved survival and quality of life compared to remaining on dialysis for most recipients, outcomes for elderly patients (older than 70 years) remain uncertain. As the number of candidates aged over 70 years seeking transplantation is increasing, we aimed to determine whether transplantation has improved outcomes for this age group.

*Methods: Using the Australia and New Zealand Dialysis and Transplant Registry (2009-2019), kidney recipients aged 70+ were matched to a maintainence dialysis patient by age, cause of ESKD and dialysis duration. We censored dialysis patients at the time of transplant. Survival was compared using Kaplan-Meier curves and Stratified Cox regression modelling, taking into account the early increased mortality post-transplant and adjustment for sex, comorbidities, smoking status and body mass index

*Results: All 465 recipients aged 70 and over at time of transplant were matched to a dialysis pair. Mortality among the transplant cohort exceeded that observed on dialysis until month 10, after which a progressive benefit in favour of transplantation was apparent (Figure 1). The early excess of deaths post-transplant was largely attributable to infection (1.9 versus 0.3 deaths per 100 patient-years) (Table 1). Over a mean follow-up of 2.6 years, risk of mortality was 60% higher for dialysis versus transplant recipients (95% CI 1.18-2.12, P=0.002). Survival at 3- and 5-years was significantly higher in the transplant group at 89% and 80% compared to 79% and 53% in the dialysis group.

*Conclusions: As compared to remaining on dialysis, elderly candidates incur an increased risk of early post-transplant mortality, predominantly due to infection, but thereafter may anticipate progressively superior rates of survival. Transplantation should be seen as the optimal means of kidney replacement therapy for suitable elderly patients.

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