*Purpose: Older donor kidneys (ODKs) are often declined as they are associated with higher post-transplant mortality and graft loss, yet those who decline may wait indefinitely for a subsequent offer. To better inform clinical decision making, we sought to characterize outcomes after declining an ODK, and determine whether there was a survival benefit from accepting ODKs.

*Methods: We used SRTR offer data from 2009-2018 to identify 102,499 candidates who were offered an ODK aged 60-88 years. We characterized outcomes among each group of ODK decliners using competing risks regression to understand this post-decision impact and used adjusted Cox regression to compare candidates’ survival after declining versus accepting an ODK.

*Results: Among candidates who declined an ODK, 45.8% were eventually transplanted, 22.4% died, and 20.3% were removed from the waitlist, and 11.5% were still waiting (Figure 1). Candidates who accepted ODK grafts had higher mortality at one-year post-transplant (5.4% vs 5.1%), but lower mortality at three years (12.0% vs 17.2%) and five years (21.4% vs 27.8%) (p<0.001). This translated in a 22% lower mortality risk for ODK acceptors compared to decliners (adjusted hazard ratio [aHR]: _0.740.78_0.82, p<0.001) (Figure 2).

*Conclusions: Acceptors of ODKs grafts received a survival benefit. Appropriate selection of ODKs may improve wait-times and survival for kidney transplant candidates.

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