*Purpose: Kidneys from older donation after cardiac death (DCD) donors are less likely to be transplanted due to concerns about inferior post-transplant survival. But candidates who declined an older DCD offer must wait for an uncertain future offer. To inform appropriate decision making and counseling, we sought to characterize the patient survival associated with accepting older DCD kidneys.

*Methods: Using SRTR data 2010-2018, we studied 71,364 adult transplant candidates who were offered an older (age ≥50) DCD kidney, and followed them from date of offer until death or administrative censoring. Offers of kidneys that were eventually discarded or never declined were excluded from the study. We compared the mortality risk of accepting versus declining the offer using Cox regression with inverse probability weights to account for confounding by candidate characteristics.

*Results: Cumulative survival of candidates who declined versus accepted an older DCD kidney was 94% vs 95% 1y, 87% vs 92% 2y, and 70% vs 82% 5y post-decision (Log-rank p<0.001). Among 88,464 candidates who declined their initial older DCD offer, only 28% eventually received a non-older DCD offer after waiting for a median 3.7 years. At 6 years after their initial older DCD offer decline, 8% of candidates were still waiting and 23% had died (Figure 1). Accepting an older DCD offer was associated with a 41% decreased risk of mortality (weighted hazard ratio: _0.520.59_0.67, p<0.001, Figure 2).

*Conclusions: Accepting older DCD kidneys was associated with a substantial survival benefit. Broader acceptance of kidney offers from well-selected older DCD donors could reduce time to transplant and improve long-term survival for kidney waitlist patients.

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