*Purpose: Pulmonary hypertension (PH) is increasingly recognized among patients with chronic kidney disease largely driven by left heart failure, high cardiac output, hypoxic lung diseases and metabolic derangements. These physiologic factors can impact post kidney transplant (KT) outcomes. The aims of this study were to analyze post KT graft and patient survival and to assess the association between donor type and outcomes in patients with pretransplant PH.

*Methods: Using USRDS data from 2000-2018, we studied 92,721 adult deceased-donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) recipients. Pretransplant PH was ascertained using one inpatient claim, two outpatient claims at least 30-days apart, and right heart catherization procedure codes within 1 year of PH diagnosis. Delayed graft function (DGF), patient survival, and death-censored graft failure were compared between recipients with and without PH using Cox regression and inverse-probability weighting.

*Results: Of 92,721 KT recipients, 2.8% (N=2570) had pretransplant PH. In a weighted, standardized population, median patient survival after KT was 9.0 years in PH and 12.8 years for non-PH patients (Figure 1). PH was associated with higher risk of DGF (OR 1.28 [1.15, 1.41], p < 0.01), death-censored graft failure (HR 1.18 [1.06, 1.30], p < 0.01) (Figure 2), and patient mortality (HR 1.54 [1.42, 1.66], p < 0.01) (Figure 1). Among those with PH, LDKT recipients had substantially decreased risk of DGF compared to DDKT recipients (OR 0.12 [0.05, 0.30], p < 0.01). The survival benefit of LDKT compared to DDKT was comparable in PH and non-PH patients (interaction p = 0.2).

*Conclusions: Pretransplant PH is associated with inferior graft and patient survival post KT. These data inform risk stratification and transplant selection process.

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