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An understanding of long-term outcomes for kidney transplant (KTx) recipients who survive with graft function beyond a specific time posttransplant is the first step in creating protocols to optimize care for current and improve outcomes for future recipients. We studied 831KTx recipients-580 living donor (LD); 251 deceased donor (DD)—with graft survival (GS) >20 years. For primary LD recipients, 25-year patient survival (PS) was 83%; 35-year, 59%. Their 25-year death-censored graft survival (DCGS) was 89%; 35-year, 72%. DD recipients had lower PS (P<0.01), DCGS (P<0.01). After 20 years, two major causes of graft loss (GL) were death with function (DwF)(58%, LD; 58%, DD) and interstitial fibrosis and tubular atrophy (IFTA)(22%, LD; 23%, DD). Two major causes of DwF were cancer (31%, LD; 31%, DD) and cardiovascular disease(CVD)(19%, LD;17%, DD). Per multivariate analysis (MVA), risk factors for GL after 20 years in pre–calcineurin inhibitor(CNI) era were human leukocyte antigen (HLA) mismatches >3 antigens, pretransplant type 1 diabetes mellitus (DM1); in CNI era, a history of rejection, female gender. New comorbidities after 20 years were common: CVD (13%, nonDM1;18%, DM1), infections (27%, non-DM1;37%, DM1), 20-29 years posttransplant. Cancer after 20 years included: nonmelanotic skin cancer,22%; solid organ,7%; post-transplant lymphoproliferative disease(PTLD),2%. To improve longterm outcomes, clinical trials on prevention, recognition, and treatment of new comorbidities are needed.

Long-Term Outcomes in 831 Kidney Transplant Recipients with 20 Years of Graft Function