Preemptively listed candidates for kidney transplant are a unique patient population with regard to marginal quality kidney acceptance as they are not yet dialysis dependent. We sought to determine if a preemptive (PE) transplant with a high KDPI (KDPI > 85) kidney provided a survival benefit over waiting without a transplant or waiting including survival associated with receiving a standard criteria donor (SCD) kidney (KDPI 21-85). As ECD transplants are rare under the age of 50, only primary PE kidney candidates and PE primary deceased donor (DD) recipients over the age of 49 in the SRTR database between 2000 and 2010 were selected. Of the 35 920 PE waitlisted candidates, 1 548 recipients of an ideal DD transplant (KDPI 0-20), 4 065 SCD recipients, and 702 high KDPI recipients were identified. Death after removal from the list was included in the analysis based on OPTN or Social Security death index data. Kaplan-Meier analysis showed initially the patients on the waiting list had a better survival than patients transplanted with a high KDPI kidney but the survival curves merged after 6 years of follow-up. Cox regression adjusting for age, race/ethnicity, gender, PRA, cause of kidney disease, and initial status at listing showed no survival benefit for high KDPI transplant over waiting without a transplant (HR 1.08, 95% CI 0.95-1.22). In a second analysis, the PE wait list population receiving an SCD organ (9 012 candidates) had better survival than those receiving high KDPI organs. Cox analysis confirmed the survival disadvantage for the high KDPI recipients (risk of patient death 1.22, 1.08-1.38). PE transplant with marginal quality organs was not associated with a survival benefit when compared to all candidates preemptively listed. The findings suggest preemptively listed patients may benefit by waiting for better quality organs.

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