Abstract Background Kidney transplantation (KT) is increasingly offered to older, comorbid patients, deemed ‘high-risk recipients’ (HRR). We aimed to quantify outcomes and predictors of mortality in HRRs in a contemporary cohort. Methods We analysed 1125 consecutive adult KT recipients (2014–2023), including 161 (14.3%) designated HRR by multidisciplinary team (MDT). Baseline donor and recipient characteristics, perioperative outcomes, and 5-year survival were compared. Predictors of mortality were assessed using multivariable Cox regression, and HRR designation was predicted via logistic regression. Red cell distribution width (RDW), a validated frailty marker, was explored as a predictor of survival. Results HRRs were older (64 versus 53 years), more frequently diabetic, and had higher rates of ischaemic heart disease (IHD). Clavien–Dindo Complications Grade ≥III occurred more frequently in HRRs (24.2% versus 16.1%, P = 0.018). Patient 5-year survival was 85.7% for standard-risk versus 67.9% for HRRs (log-rank P 0.0001). In adjusted multivariable Cox regression, age (HR 1.86 per decade, 95%c.i. 1.52–2.28), IHD (HR 2.53, 95%c.i. 1.47–4.33), retransplantation (HR 2.10, 95%c.i. 1.17–3.77), and RDW (HR 1.23 per 1% increase, 95%c.i. 1.09–1.39) independently predicted mortality (P 0.001). Logistic regression indicated that age, diabetes, IHD, and prolonged waiting list duration predicted MDT high-risk designation (AUC 0.83). When HRR status alone was used in the model, it predicted worse 5-year survival (HR 1.86, 95%c.i. 1.16–2.96, P = 0.01). Conclusions HRRs experience lower 5-year survival. Recipient age and elevated RDW are dominant predictors of mortality, supporting integration of objective metrics with the already robust MDT assessment to improve prognostication and patient counselling.
Spiers et al. (2026) studied this question.