*Purpose: Increasing the number of organs available for transplantation could reduce waitlist morbidity and mortality for patients with end organ failure. Most transplanted organs come from donors meeting an organ-specific eligibility definition prescribed by the OPTN. However, many successful transplants involve donors who do not meet all criteria (i.e.“ineligible” donors). We aimed to analyze survival differences between recipients of eligible and ineligible organ donations and model the impact of increased ineligible donor use.

*Methods: We combined OPTN STAR file data with OPTN-provided data of all eligible deaths from 2008-2017. We fit Kaplan-Meier survival curves for eligible and ineligible solid-organ donation recipients and compared survival outcomes via log rank tests. We used Cox regression to study the association of eligibility with survival when controlling for patient characteristics (e.g. sex, age, BMI, etc.). Finally, we estimated life-years gained had OPOs increased ineligible donor utilization rates to the 75^th percentile.

*Results: 77,576 adult donors met inclusion criteria. Figure 1 shows patient survival by organ and donor eligibility. Recipients of ineligible kidney, lung, and pancreas donations had no significant difference in survival compared to eligible donations (p=0.24, 0.49, 0.86, respectively). Heart and liver transplants using ineligible donors saw an 8.5% (p=0.03) and 3.6% (p<0.01) reduction in 5-year survival, respectively. When accounting for patient characteristics, donor eligibility had a significant positive association with survival (hazard ratio: 1.14; 95% CI: (1.10, 1.18); p<0.01). Across OPOs, ineligible donor use ranged from 5%-39% of donors. Had OPOs increased ineligible donor use to meet the 75^th percentile, 9,450 additional organs would have been available for transplant over the 10-year period, enabling an estimated 51,786 additional life-years saved.

*Conclusions: Using organs from ineligible donors offers a survival benefit for waitlisted candidates who may otherwise never receive a transplant. Heart and liver recipients have decreased relative survival with ineligible compared to eligible donor use, however improving utilization can improve the number of organs available for transplantation. Further analyses defining ineligible donors that yield optimal recipient outcomes are warranted.

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