“Rethinking High‐KDPI Kidneys: A Multidomain Approach to Predicting Success”

ABSTRACT Background The allocation and acceptance of deceased‐donor kidneys in the United States is influenced by theKidney Donor Profile Index (KDPI). We conducted a national analysis of high‐KDPI kidney transplants performed from 2014 to 2021 to identify key predictors of post‐transplant outcomes beyond those incorporated in KDPI. Methods This retrospective cohort study used data extracted from the Scientific Registry of Transplant Recipients (SRTR). Adult, first‐time recipients of kidney‐only deceased‐donor transplants with KDPI greater than 85% were included. Regression models were used to identify independent predictors of delayed graft function (DGF), primary graft nonfunction (PGNF), patient survival, overall graft survival, and death‐censored graft survival. Results Among 4,911 recipients, DGF occurred in 33.8% and PGNF in 4.0%. DGF was independently associated with donation after circulatory death, terminal donor creatinine > 1.5 mg/dL, recipient obesity, dialysis duration > 3 years, and cold ischemia time (CIT) ≥ 24 h, whereas machine perfusion was protective. PGNF was associated with donation after circulatory death, terminal donor creatinine > 2.0 mg/dL, high‐risk cytomegalovirus (CMV) serostatus, and donor injury patterns within the high‐KDPI range, including younger donor age. Five‐year patient and graft survival were 72% and 62%, respectively. Graft loss was independently associated with DGF, elevated intrarenal resistive index (RI), recipient diabetes, prolonged dialysis exposure, and high‐risk CMV/EBV serostatus. Conclusions Outcomes after high‐KDPI kidney transplantation reflect both KDPI‐defined donor risk and additional recipient, immunologic, and perioperative factors. A multidomain, offer‐time assessment may support more individualized acceptance decisions and improve utilization.