The Evolving Kidney Donor Pool Shaping Outcomes in Graft Survival

The composition of the U.S. deceased kidney donor pool is undergoing a major shift. While the past decade saw an increase in younger, overdose-death donors associated with favorable transplant outcomes, recent years have marked a decline in these donors. Concurrently, there has been a rise in higher-risk donor characteristics-namely, older age, more comorbidities, such as hypertension and diabetes, and increased reliance on donation after circulatory death (DCD). These trends may significantly affect transplant outcomes.

We analyzed data from the Organ Procurement and Transplantation Network (OPTN) on 101,550 deceased kidney donors (2018-Q1 2025) and 108,611 single kidney transplants (2018-mid-2024). Donor trends were assessed using segmented regression analysis. Graft survival was evaluated using Kaplan-Meier survival curves and multivariable Cox proportional hazards models, adjusting for donor, recipient, and transplant characteristics.

Overdose-death donors declined from 16.7% in 2022 to 10.5% by Q1 2025. Simultaneously, DCD donors rose to nearly 50% of all deceased donors. The proportion of older donors and high-KDPI kidneys also increased. Kaplan-Meier analysis showed a decrease in unadjusted death-censored graft survival in 2024 compared to 2018-2022 (97.0% vs. 97.6%, p < 0.001). In adjusted Cox models, donor factors-DCD status, older age, hypertension, diabetes, and prolonged cold ischemia-were independently associated with graft loss.

The U.S. kidney donor pool is shifting toward higher-risk profiles, with early signs of declining graft survival. Strategies to optimize organ preservation and allocation will be essential to maintain transplant outcomes amid these changing donor trends.