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WHAT IS ALREADY KNOWN ON THIS TOPIC Diabetes is the leading cause of end-stage renal disease in the USA, and kidney transplantation offers substantial survival benefit over maintenance dialysis. Despite this benefit, patients with diabetes are less likely to be listed for transplantation and more likely to be removed from the waiting list than patients without diabetes, making it critical to quantify the survival benefit of living and deceased donor kidney transplantation in this population.WHAT THIS STUDY ADDS Living donor kidney transplantation provides the greatest survival benefit for patients with diabetes, who continue to face disparities in access to transplantation and frequently receive lower-quality grafts compared with patients without diabetes.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY Targeted efforts to expand living donor kidney transplantation for patients with diabetes (eg, pre-emptive living donor kidney transplantation, prioritizing patients with diabetes in donation chains, tailored living donor education) should be implemented to reduce disparities in waitlist outcomes and graft allocation.Introduction Diabetes is the leading cause of end-stage renal disease (ESRD) in the USA. Kidney transplantation is the best treatment for patients with ESRD and improves long-term survival compared with maintenance dialysis. 1 For patients with diabetes on maintenance dialysis in the USA, deceased donor kidney transplantation (DDKT) has been shown to increase survival by 11 years.2Despite the high mortality risk associated with diabetes-related ESRD3 and the survival benefit of kidney transplantation,2 patients with diabetes are less likely to be added to the kidney transplant waiting list and more likely to be removed from it.4 5 Once added to the waitlist, patients with diabetes are less likely to undergo both deceased and living donor kidney transplantation (LDKT).6 7National kidney transplantation rates among patients with diabetes have been explored in other countries,8–10 but similar studies that evaluate the benefit of renal transplantation among patients with diabetes in the USA are needed, as differences in kidney allocation policies (eg, presence vs absence of longevity matching, influence of geographical distribution) may significantly influence access to transplantation and subsequent outcomes. To address this gap, we evaluated waiting list and post-transplant outcomes for patients with diabetes as the primary cause of ESRD in the USA. The primary objective of this study was to quantify the survival benefit of DDKT and LDKT among patients with diabetes. Secondary objectives examined the effect of diabetes on waitlist failure and access to transplantation.Methods Study population This study used data from the United Network for Organ Sharing Kidney Standard Transplant Analysis and Research (STAR) file. The STAR dataset includes information on waitlisted candidates and transplant recipients in the USA. Data is collected by the Organ Procurement and Transplantation Network (OPTN).The study population (N=417,436) included all adults who were placed on the waiting list for kidney transplantation between January 1, 2014, and January 1, 2024. All inactive and active patients were included, and patients with multiple listings (n=36,044) were only included at their first listing date. Patients were excluded if they were missing ethnicity (n=83) or peripheral vascular disease (PVD) diagnosis at registration (n=3,069) to ensure complete covariates. Additionally, patients were excluded if they were listed for and/or received multiorgan transplants or if they had a prior organ transplant. Online supplemental figure S1 provides a detailed population workflow diagram.SP110.1136/bmjdrc-2025-005691.supp1Supplementary dataThis study analyzed de-identified data obtained through approved access to the United Network for Organ Sharing STAR file. Per institution policy, institutional review board review and informed consent were not required.Statistical analysis Patients were stratified on whether diabetes was the primary cause of kidney failure. Patients with diabetes included individuals diagnosed with type 1 diabetes, type 2 diabetes, or other/unspecified forms of diabetes. Patients without diabetes included all other causes of ESRD (glomerulonephritis, hypertension, etc). Individuals with diabetes but other primary causes of ESRD were classified as patients without diabetes.For baseline demographics, categorical outcomes were reported as numbers and percentages (%) and compared using the Pearson’s χ2 test. Continuous variables were summarized by medians and interquartile ranges and compared using the Wilcoxon rank-sum test.Survival times for waitlisted candidates began at the date of listing and ended at the date of death. Survival times for transplanted patients began at the date of transplant and ended at the date of death.Waitlist failure was defined as death or waitlist removal due to the patient being too sick to transplant. Patients with no documented date of death or waitlist removal were censored and presumed to be alive as of September 30, 2024.Post-transplant failure was defined as the earliest record of graft failure, death, or the need to resume maintenance dialysis. Patients with no documented date of failure or follow-up were presumed to be alive as of September 30, 2024.To evaluate waitlist failure, univariate and multivariate Fine and Gray analyses were performed, with transplant (DDKT, LDKT, or both) as a competing risk.11 Cumulative incidence curves visualized time-to-event data.12Univariate and multivariate Cox regressions compared waitlist and post-transplant survival. Life-years gained were calculated from the area under the survival curve and were truncated at 10 years to avoid extrapolating beyond observed follow-up. Survival times for life-years gained began at the date of listing and ended at the time of death. Estimates reflect the average age within each cohort and do not account for individual differences in recipient age.To estimate life-years from transplant, a lognormal survival regression projected the survival curve to 10,000 days (328.77 months), and the median waitlist time awarded in months was subtracted from the projected post-transplant survival estimate.13Waitlist and post-transplant survival were summarized using the Kaplan-Meier method and compared between groups using the log-rank test. Time to equal risk (ER) was reported as the month at which waitlist and transplant survival intersected. Time to equal survival (ES) was reported as the month at which the cumulative areas under the survival curves for transplanted and waitlisted patients were equal.2Univariate and multivariate Cox regressions compared post-transplant failure for DDKT and LDKT recipients and between patients with and without diabetes. Post-transplant failure for DDKT recipients was not adjusted for known donor risk factors or Kidney Donor Profile Index (KDPI) scores to reflect allocation patterns between patients with and without diabetes. A p value of <0.05 was considered statistically significant. All analyses were performed using Stata, V.19.5 (StataCorp, College Station, Texas, USA).Results Baseline demographics A total of 276,069 patients were included in the final analysis. Patients were mostly male (62%) with a median age of 55 years at listing and spent a median of 16 months on dialysis before listing. Most patients (60%) did not have diabetes as a cause of ESRD ( table 1), and the proportion of candidates with diabetes varied across the USA (online supplemental figure S2). There was no correlation between state-level obesity prevalence14 and diabetes prevalence among waitlisted candidates (r=0.04, p=0.77), as shown in online supplemental figure S3. Baseline demographics and waitlist outcomes, stratified by diabetes subtypes, can be found in online supplemental table S1.Table 1Baseline demographic variables and outcomes of patients added to the national kidney transplant waiting listOverallN=276,069Diabetesn=109,098No diabetesn=166,971P valueAge at listing (years)55 (44–63)58 (50–65)52 (40–62)<0.001Sex (female)104,193 (38%)36,702 (34%)67,491 (40%)<0.001Race White111,469 (40%)36,626 (34%)74,843 (45%)<0.001 Black81,450 (30%)33,148 (30%)48,302 (29%)<0.001 Hispanic/Latino55,333 (20%)27,045 (25%)28,288 (17%)<0.001 Asian21,731 (8%)9,067 (8%)12,664 (8%)<0.001 American Indian/Alaska Native2,513 (0.9%)1,526 (1%)987 (0.6%)<0.001 Native Hawaiian/Other Pacific Islander1,467 (0.5%)840 (0.8%)627 (0.4%)<0.001 Multiracial, non-Hispanic2,106 (0.8%)846 (0.8%)1,260 (0.8%)0.54BMI (kg/m²) BMI at listing29.1 (25.3–33.3)30.4 (26.8–34.2)28.1 (24.4–32.5)<0.001 Overweight90,032 (33%)35,137 (32%)54,895 (33%)<0.001 Class I obesity75,017 (27%)35,879 (33%)39,138 (23%)<0.001 Class II obesity39,205 (14%)19,010 (17%)20,195 (12%)<0.001 Class III obesity8,545 (3%)3,560 (3%)4,985 (3%)<0.001Blood type A89,126 (32%)35,301 (32%)53,825 (32%)0.51 AB10,748 (4%)4,313 (4%)6,435 (4%)0.19 B41,225 (15%)16,814 (15%)24,411 (15%)<0.001 O134,970 (49%)52,670 (48%)82,300 (49%)<0.001Dialysis before listing (months)16 (8–34)16 (8–32)16 (8–37)<0.001Peripheral vascular disease33,284 (12%)22,429 (21%)10,855 (7%)<0.001Waitlist morbidity and mortality Removal, too sick22,502 (8%)13,070 (12%)9,432 (6%)<0.001 Died23,331 (8%)14,232 (13%)9,099 (5%)<0.001 Failures per 100 patient-years8115—BMI, body mass index; class III obesity, BMI ≥40 kg/m2; class II obesity, BMI 35–39 kg/m2; class I obesity, BMI 30–34 kg/m2; overweight, BMI 25–29 kg/m2.Of the 166,971 candidates without diabetes, 54% received a transplant. In comparison, significantly fewer patients with diabetes (38%) were transplanted (p<0.001). Among transplanted patients, those with diabetes experienced longer cold ischemia times (16.5 hours vs 13.1 hours, p<0.001), had older donors (45 years vs 40 years, p<0.001), and received higher KDPI grafts (49% vs 35%, p<0.001) compared with those without diabetes (table 2). KDPI distribution by diabetes status and recipient age is shown in online supplemental figure S4. Baseline demographics, transplant clinical factors, and donor characteristics for transplanted patients with diabetes, stratified by diabetes subtypes, can be found in online supplemental table S2.Table 2Baseline demographics, donor characteristics, and postoperative outcomes of transplanted patientsOverallN=132,676Diabetesn=41,848No diabetesn=90,828P valueAge at listing (years)53 (42–62)58 (51–65)50 (38–61)<0.001Sex (female)51,879 (39%)14,296 (34%)37,583 (41%)<0.001Race White57,046 (43%)14,672 (35%)42,374 (47%)<0.001 Black37,643 (28%)13,118 (31%)24,525 (27%)<0.001 Hispanic/Latino25,635 (19%)9,646 (23%)15,989 (18%)<0.001 Asian9,612 (7%)3,226 (8%)6,386 (7%)<0.001 American Indian/Alaska Native1,086 (0.8%)564 (1%)522 (0.6%)<0.001 Native Hawaiian/Other Pacific Islander604 (0.5%)286 (0.7%)318 (0.4%)<0.001 Multiracial, non-Hispanic1,050 (0.8%)336 (0.8%)714 (0.8%)0.75BMI (kg/m²) BMI at listing28.6 (24.9–32.9)30.3 (26.8–34)27.8 (24.1–32.2)<0.001 Overweight43,777 (33%)13,714 (33%)30,063 (33%)0.24 Class I obesity34,466 (26%)13,879 (33%)20,587 (23%)<0.001 Class II obesity17,383 (13%)7,076 (17%)10,307 (11%)<0.001 Class III obesity3,567 (3%)1,116 (3%)2,451 (3%)0.74Waitlist time awarded (months)33 (14–61)37 (17–62)31 (13–60)<0.001Donor characteristics Age (years)42 (31–53)45 (35–55)40 (29–52)<0.001 CIT (hours)14.3 (2.7–21.3)16.5 (6–22.5)13.1 (2–20.5)<0.001 DCD*27,984 (31%)10,497 (34%)17,487 (30%)<0.001 ECD*14,494 (16%)6,689 (21%)7,805 (13%)<0.001 Living42,702 (32%)10,687 (26%)32,015 (35%)<0.001KDPI (%)40 (21–62)49 (31–68)35 (15–59)<0.001Postoperative morbidity and mortality 1-year death3,774 (3%)1,943 (5%)1,831 (2%)<0.001 1-year graft failure3,228 (2%)1,123 (3%)2,105 (2%)<0.001 Hospital LOS (days)4 (3–6)5 (4–6)4 (3–5)<0.001 Failures per 100 patient-years584—*Among deceased donors.BMI, body mass index; CIT, cold ischemia time; class III obesity, BMI ≥40 kg/m2; class II obesity, BMI 35–39 kg/m2; class I obesity, BMI 30–34 kg/m2; DCD, donation after circulatory death; ECD, extended criteria donor; KDPI, Kidney Donor Profile Index; LOS, length of stay; overweight, BMI 25–29 kg/m2.Waitlist failure 10 years after listing, patients with diabetes experienced greater waitlist failure in comparison to those without (84% vs 62%, p<0.001), as shown in figure 1. Waitlist failure, stratified by diabetes subtypes, can be found in online supplemental figure S5a.Figure 1Unadjusted waitlist failure-free survival, stratified by diabetes-related end-stage renal disease, censored for deceased and living donor kidney transplantation.On univariate analysis, compared with patients without diabetes, those with diabetes were more likely to experience waitlist failure at 1 year (subdistribution HR (SHR) 2.14, 95% CI 2.06 to 2.23, p<0.001), 5 years (SHR 2.27, 95% CI 2.22 to 2.32, p<0.001), and 10 years (SHR 2.27, 95% CI 2.23 to 2.32, p<0.001) after listing (figure 2a), which remained significant on multivariate analysis (table 3). Two separate models, one adjusting for waitlist time awarded and one using both DDKT and LDKT as competing risks, produced similar results (online supplemental tables S3, S4).Figure 2Cumulative incidence function curves demonstrating (a) probability of waitlist failure with DDKT as a competing risk, (b) probability of DDKT with waitlist failure as a competing risk, and (c) probability of DDKT or LDKT with waitlist failure as a competing risk. DDKT, deceased donor kidney transplantation; LDKT, living donor kidney transplantation; WL, waitlist.Table 3Univariable and multivariable subdistribution hazard model for 10-year failure on the kidney transplant waiting list, censored for LDKTSHR95% CIP valueSHR95% CIP valueAge at listing (per year)1.041.04 to 1.04<0.0011.031.03 to 1.03<0.001Sex, male reference0.840.83 to 0.86<0.0010.910.89 to 0.93<0.001Blood type, A reference AB0.740.70 to 0.79<0.0010.760.72 to 0.81<0.001 B1.101.07 to 1.13<0.0011.191.15 to 1.22<0.001 O1.121.10 to 1.14<0.0011.201.18 to 1.23<0.001Ethnicity, white reference Black0.770.75 to 0.79<0.0010.810.80 to 0.83<0.001 Hispanic/Latino0.780.76 to 0.80<0.0010.790.77 to 0.82<0.001 Asian0.710.69 to 0.74<0.0010.710.68 to 0.73<0.001 American Indian/Alaska Native0.990.91 to 1.080.760.910.83 to 0.990.03 Native Hawaiian/Other Pacific Islander0.820.73 to 0.920.0010.820.73 to 0.930.002 Multiracial, non-Hispanic0.760.68 to 0.84<0.0010.830.74 to 0.920.001Peripheral vascular disease1.381.35 to 1.42<0.0011.041.01 to 1.060.01Diabetes2.272.23 to 2.32<0.0012.011.97 to 2.05<0.001LDKT, living donor kidney transplantation; SHR, subdistribution HR.Among patients who died on the waitlist, most causes were listed as unknown (46%). For patients with known causes of waitlist mortality, cardiovascular events were the most common cause of death (23%), and patients with diabetes were more likely than those without diabetes to die from cardiovascular-related events (24% vs 20%, p<0.001).Probability of deceased or living donor transplantation On univariate analysis, patients with diabetes were less likely to undergo DDKT or LDKT (SHR 0.61, 95% CI 0.60 to 0.62, p<0.001), as shown in figure 2c. The effect of diabetes on access to DDKT or LDKT remained significant on multivariate analysis adjusting for age at listing, sex, blood type, ethnicity, and PVD at registration (SHR 0.63, 95% CI 0.63 to 0.64, p<0.001). At each year between 2014 and 2024, a smaller proportion of patients with diabetes were transplanted than those without (online supplemental table S5).Probability of deceased donor transplantation As time on the waiting list increased, the gap in access to DDKT between patients with and without diabetes increased ( figure 2b). 1 year after listing, patients with diabetes had a 5% lower probability of transplantation in comparison to those without. This difference increased to 12% and 13% at 5 years and 10 years, respectively. 90% of DDKT occurred within 54 months (95% CI 54 to 55 months) of listing for patients with diabetes and within 56 months (95% CI 55 to 56 months) of listing for those without diabetes.Probability of living donor transplantation Compared with patients without diabetes, those with diabetes were less likely to undergo LDKT (SHR 0.46, 95% CI 0.45 to 0.47, p<0.001). From 2014 to 2024, patients with diabetes consistently had fewer living donors per 100 transplants than those without ( online supplemental figure S6).While patients with diabetes were less likely to undergo LDKT than DDKT, having a living donor increased their odds of transplantation within 1 year (SHR 1.67, 95% CI 1.62 to 1.71, p<0.001), 5 years (SHR 1.80, 95% CI 1.76 to 1.84, p<0.001), and 10 years (SHR 1.79, 95% CI 1.75 to 1.83, p<0.001) after listing. 90% of LDKT occurred within 26 months (95% CI 26 to 27 months) of listing for patients with diabetes and within 28 months (95% CI 28 to 29 months) of listing for those without diabetes.Survival benefit of transplantation Among patients with diabetes, LDKT offered significant survival benefit (42 deaths per 1,000 patient-years) compared with remaining on the waiting list (79 deaths per 1,000 patient-years), as shown in figure 3a. Over a 10-year horizon, LDKT recipients gained an additional 1.90 life-years (29% increase in relative survival), as shown in table 4. The survival benefit of LDKT, compared with remaining on the waiting list, remained significant at 10 years on multivariate analysis (HR 0.41, 95% CI 0.39 to 0.43, p<0.001) (online supplemental table S6).Figure 3Survival benefit of transplantation for patients with and without diabetes, demonstrating (a) number of deaths per 1,000 patient-years and (b) life-years from transplant compared with receiving no transplant. DDKT, deceased donor kidney transplantation; LDKT, living donor kidney transplantation.Table 4Restricted mean survival time over 10 years, comparing waitlisted and transplanted patients, stratified by diabetes statusWaitlistsurvival(years)DDKTsurvival(years)LDKTsurvival(years)DDKTrelativeyearsgainedLDKTrelativeyearsgainedDDKTrelativeyearsgained (%)LDKTrelativeyearsgained (%)Diabetes6.498.038.391.541.9023.7%29.3%No diabetes7.799.009.411.211.6215.5%20.8%DDKT, deceased donor kidney transplantation; LDKT, living donor kidney transplantation.LDKT also offered significant survival benefit among patients without diabetes (15 deaths per 1,000 patient-years) compared with remaining on the waiting list (44 deaths per 1,000 patient-years), and LDKT recipients gained an additional 1.62 life-years (21% increase in survival) over a 10-year horizon (figure 3a; table 4). The survival benefit of LDKT for patients without diabetes, compared with remaining on the waiting list, remained significant on multivariate analysis (online supplemental table S7).Among patients with diabetes, DDKT offered a significant survival benefit (70 deaths per 1,000 patient-years) compared with remaining on the waiting list (79 deaths per 1,000 patient-years). Likewise, DDKT offered significant survival benefit for patients without diabetes (33 deaths per 1,000 patient-years) compared with remaining on the waiting list (44 deaths per 1,000 patient-years), as shown in figure 3a. The survival benefit of DDKT for patients with and without diabetes remained significant on multivariate analysis (online supplemental tables S8, S9).In comparison to DDKT, LDKT offered more life-years from transplant (18.2 years vs 14.1 years) and more life-years gained (1.90 years vs 1.54 years over a 10-year horizon, p<0.001) for patients with diabetes (figure 3b; table 4). LDKT recipients with diabetes had decreased 1-year post-transplant failure (HR 0.32, 95% CI 0.28 to 0.37, p<0.001) and 1-year post-transplant death rates (2% vs 6%, p<0.001) compared with DDKT recipients with diabetes. LDKT was also associated with decreased risk of 5-year post-transplant mortality (HR 0.50, 95% CI 0.46 to 0.53, p<0.001), as shown in figure 4c. LDKT recipients with diabetes reached ES and ER at 1 month, and DDKT recipients with diabetes reached ES and ER at 20 and 31 months (figure 4a, b). Post-transplant survival, stratified by diabetes subtypes, can be found in online supplemental figures S5b,c.Figure 4Survival among patients with diabetes (a–c) and patients without diabetes (d–f): (a, d) those remaining on the waitlist versus those receiving LDKT, (b, e) those remaining on the waitlist versus DDKT recipients, and (c, f) post-transplant survival comparing LDKT and DDKT recipients. Both LDKT recipients with and without diabetes had ES and ER at 1 month compared with waitlisted patients. DDKT recipients with diabetes reached ES at 20 months and ER at 31 months compared with waitlisted patients, and DDKT recipients without diabetes reached ES and ER at 10 and 17 months, respectively, compared with patients on the waiting list. DDKT, deceased donor kidney transplantation; ER, equal risk; ES, equal survival; LDKT, living donor kidney transplantation; WL, waitlist.For patients without diabetes, LDKT offered more life-years from transplant than DDKT (22.9 years vs 18 years) and life-years gained (1.62 years vs 1.21 years over a 10-year horizon, p<0.001) (figure 3b; table 4). Compared with DDKT recipients without diabetes, LDKT recipients without diabetes had decreased post-transplant failure (HR 0.33, 95% CI 0.30 to 0.37, p<0.001) and death rates (0.9% vs 3%, p<0.001) at 1 year. LDKT was also associated with decreased risk of 5-year post-transplant mortality (HR 0.40, 95% CI 0.38 to 0.42, p<0.001), as shown in figure 4f. LDKT recipients had ES and ER at 1 month and DDKT recipients had ES and ER at 10 and 17 months (figure 4d, e).Additional analyses estimated life-years gained by comparing post-transplant survival to waitlist failure rather than waitlist mortality. Results are reported in online supplemental table S10.Transplant outcomes among patients with and without diabetes Among all transplant recipients, patients with diabetes were more likely to experience post-transplant failure (HR 1.85, 95% CI 1.75 to 1.95, p<0.001) and death (HR 2.43, 95% CI 2.27 to 2.60, p<0.001) at 1 year.Diabetes was a significant predictor of 1-year post-transplant failure for DDKT (HR 1.71, 95% CI 161 to 1.81, p<0.001) and LDKT recipients (HR 1.66, 95% CI 1.42 to 1.93, p<0.001), which remained significant on multivariate analysis (online supplemental tables S11, S12). Diabetes was also a significant predictor of 1-year post-transplant death for DDKT (HR 2.20 95% CI 2.04 to 2.37, p<0.001) and LDKT recipients (HR 2.51, 95% CI 2.06 to 3.05, p<0.001).Most causes of graft failure (31%) and post-transplant mortality (23%) were unspecified. Chronic rejection (21%) and acute rejection (15%) were the leading causes of known graft failure. For patients with known causes of post-transplant mortality, cardiovascular events were the most common (12%) cause of death, and patients with diabetes were more likely to die from cardiovascular-related events in comparison to those without diabetes (14% vs 11%, p<0.001). The presence of PVD, in particular, was associated with increased mortality risk among DDKT recipients. On multivariate analysis adjusting for age, sex, KDPI, and donor type (DCD vs DBD), patients with both diabetes and PVD were more than twice as likely to experience 1-year post-transplant mortality (2.27, 95% CI 2.05 to 2.52, p<0.001) compared with patients without diabetes or PVD. Among patients without diabetes, the effect of PVD on post-transplant mortality remained significant, although slightly attenuated (HR 1.63, 95% CI 1.42 to 1.88, p<0.001). A similar pattern was observed for graft failure: PVD increased post-transplant failure in both patients with diabetes (HR 1.82, 95% CI 1.66 to 1.99, p<0.001) and those without diabetes (HR 1.49, 95% CI 1.33 to 1.68, p<0.001).Discussion Diabetes remains the leading cause of ESRD, yet patients with diabetes undergo renal transplantation at nearly one-third the rate of patients with glomerulonephritis. 7 Our analysis confirms that patients with diabetes face significant disadvantages in accessing both DDKT and LDKT. However, evidence reveals that transplantation offers substantial benefit, with LDKT and DDKT respectively providing 18.2 and 14.1 life-years from transplant and increasing relative years-gained by over 20%. As such, it is crucial to characterize waitlist and post-transplant outcomes for patients with diabetes.Consistent with national6 9 15 16 and single-center15 17 studies, we found that patients with diabetes were disadvantaged on the waiting list, as they were twice as likely to experience waitlist failure (table 3) and had a 0.61 likelihood of transplantation compared with patients without diabetes over 10 years. Importantly, disparities in DDKT access widened over time; as waiting list time increased from 1 to 10 years, the difference in DDKT probability became more pronounced for patients with and without diabetes (figure 2b).When patients with diabetes did undergo DDKT, they were more likely to receive extended criteria donor kidneys, experience longer cold ischemia times, and have greater KDPI scores, all of which are associated with shorter graft half-life.18 These allocation trends likely reflect the Kidney Allocation System’s desire to improve longevity matching by allocating low KDPI kidneys to patients with high estimated post-transplant survival.19 It is well established that patients with diabetes are more likely to develop cardiovascular disease, including PVD, which is independently associated with worse post-transplant survival. Lower survival in patients with diabetes limits their access to low KDPI kidneys and results in the allocation of higher-risk grafts to these individuals. Indeed, across all age groups patients with diabetes consistently receieved higher KDPI grafts (online supplemental figure S4). High KDPI grafts are harder to match and face longer cold ischemia times, likely accounting for the relationship between diabetes and cold ischemia time.20 21 Together, these donor, recipient, and transplant characteristics explain the major differences we observed in post-transplant survival among DDKT recipients with diabetes.Importantly, DDKT recipients had worse survival outcomes than LDKT recipients, particularly among those with diabetes. Within this group, DDKT recipients had ES and ER time points of 20 and 31 months compared with patients who remained on the waitlist (figure 4). Conversely, patients with diabetes who underwent LDKT reached ES and ER at 1 month. This increase in ES by 19 months and ER by 30 months highlights the risk of early post-transplant death among DDKT recipients. Indeed, DDKT recipients with diabetes had a death rate that was double that of LDKT recipients with diabetes in the first year post-transplant and were three times as likely to experience 1-year post-transplant failure. These findings suggest that LDKT provides higher quality grafts and reduces cold ischemia times, improving post-transplant outcomes.Post-LDKT outcomes among patients with diabetes can also be explained by time spent on the waiting list. We found that LDKT cuts wait time in half: 90% of living donor transplants occurred within 26 months of listing, more than twice as fast as deceased donor transplants. Because LDKT decreases time spent on the waiting list, and each additional year of dialysis therapy is associated with worse post-transplant outcomes,22 securing a living donor offers significant survival benefit, with pre-emptive LDKT being the best option available.Collectively, both marginal graft quality (eg, high KDPI organs and long cold ischemia times) and time on the waiting list decrease the value of DDKT and suggest that LDKT offers the greatest benefit to ESRD patients.23 24 This survival benefit is particularly enhanced among patients with diabetes; the risk reduction of LDKT compared with DDKT, quantified by reduction in time to ES, was greater for those with diabetes than those without (19 months vs 9 months). Additionally, over a 10-year horizon, LDKT recipients with diabetes experienced the greatest gain in life-years, with a relative increase of 29%, compared with 24% for DDKT recipients with diabetes and 21% for LDKT recipients without diabetes. This advantage was more pronounced when comparing post-transplant survival with waitlist failure (death or removal due to being too sick to transplant): LDKT recipients with diabetes experienced a 78% relative increase in life-years gained, nearly 1.5 times greater than LDKT recipients without diabetes (online supplemental table S10).Despite the clear advantage of LDKT, patients with diabetes were less likely to undergo LDKT, and living donor transplants accounted for a smaller proportion of total transplants among these individuals, suggesting that patients with diabetes have a low probability of securing a living donor. This trend may be explained by the link between family history and diabetes status, which can reduce the number of biologically related individuals that are eligible to donate. Historically, potential donors with pre-existing diabetes were excluded from living kidney donation, but following the implementation of OPTN Policy 14.4E on July 26, 2022, those with diabetes could be considered for living kidney donation.25 Nevertheless, our analysis of patients listed in 2023 found that candidates with diabetes were still less likely to undergo LDKT (online supplemental table S13), potentially reflecting implementation lag, hesitancy in using donor kidneys from patients with diabetes, and socioeconomic barriers.Our study has multiple strengths, including its national representation of renal transplant candidates and study duration of 10 years. Moreover, our robust subgroup analysis and stratification into living and deceased donor transplants provide insight into the survival advantages of LDKT among patients with and without diabetes. However, several limitations must be considered. Selection bias is likely, as there may be variation in listing practices across centers. Additional unmeasured factors, such as the duration of diabetes, pre-transplant and post-transplant glycemic control, and the development of cardiovascular comorbidities, could significantly influence patient outcomes. Lastly, our analysis relied on extrapolation for life-years from transplantation, and mean survival times represented average recipient age and were truncated at 10 years due to limited long-term transplant follow-up data.In conclusion, proceeding to transplantation offers significant survival advantages for ESRD patients with diabetes. Those with diabetes are significantly disadvantaged for waitlist placement and access to transplantation. Living donor kidney transplantation is necessary to reduce barriers to transplantation and improve post-transplant outcomes among this high-risk population. While patients with diabetes are at increased risk for post-transplant failure, targeted efforts (eg, pre-emptive living donor kidney transplantation, prioritizing patients with diabetes in donation chains, tailored LDKT education, expanding Living Donor Champions) should be made to increase living donor access among patients with diabetes. Future work should quantify the clinical value and economic benefit of living and deceased donor kidney transplantation for patients with diabetes in the USA.