Abstract
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.