Is Age Just a Number? Access to and Outcomes in Kidney Transplant Recipients ≥65 Years

Background: Individuals ≥65 years old represent the fastest-growing segment of the US and ESRD populations. This analysis assessed trends in kidney transplant (KTX) access and outcomes in patients <65 vs ≥65 years. Study Design: We conducted a longitudinal cohort study using merged UNOS, USRDS, and Vizient data. UNOS included patients waitlisted and transplanted at the study institution through 2025. USRDS provided ESRD prevalence (2020–2022), and Vizient provided outcomes data (2022–2024). Results: ESRD prevalence was nearly fourfold higher in ≥65-year-olds vs <65 (6.0 vs 1.6 per 1,000). The proportion of ≥65-year-olds added to the institutional KTX waitlist rose from 2% in 1990 to 22% in 2025, while they represented 43% of ESRD patients. KTX outcomes (2022–2024) included 974 patients (759 <65 vs 215 ≥65 yo). Groups were similar for sex and race/ethnicity. Patients ≥65 had lower BMI, shorter dialysis duration, longer waitlist time, higher diabetes prevalence, and more marginal donor organs. Perioperative outcomes and resource use were similar. Older patients had higher rates of delayed graft function and discharge to rehab but similar length of stay, complications, readmissions, and costs. Graft survival was excellent and comparable between groups. Overall mortality was very good, slightly lower at 2–3 years in those ≥65. Conclusions: Patients ≥65 represent the fastest-growing ESRD segment. Although KTX access has improved, older patients remain underrepresented on waitlists. Outcomes and costs for select older recipients are comparable to younger patients. Further research is needed to safely expand KTX access in this population.