Kidney donor profile index (KDPI) score and long-term deceased donor kidney transplant outcomes: A systematic review and meta-analysis of cohort studies

The Kidney Donor Profile Index (KDPI) summarizes the expected longevity of deceased-donor kidneys, but its relationship with long-term graft outcomes and its performance outside the United States remain uncertain. We systematically reviewed cohort evidence evaluating KDPI and long-term deceased-donor kidney transplant outcomes. MEDLINE, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov were searched from January 2014 through June 2026. Eligible studies included at least 100 adult deceased-donor kidney recipients with outcomes assessed at a minimum three-year horizon. Adjusted hazard ratios (HRs) for death-censored graft failure were standardized to a 10-point KDPI increase and pooled using a random-effects model with restricted maximum likelihood and modified Hartung-Knapp intervals. Thirteen publications were included; five studies comprising 2902 recipients contributed comparable adjusted estimates. Each 10-point increase in KDPI was associated with a higher rate of death-censored graft failure (HR 1.19, 95% CI 1.08-1.31; I2 = 43.8%; 95% prediction interval 0.97-1.46). Restriction to three studies with explicit long-term follow-up yielded HR 1.14 (95% CI 1.02-1.27; I2 = 14.2%). The exploratory KDPI >85% analysis was imprecise (HR 2.13, 95% CI 0.75-6.02). Reported KDPI discrimination was generally limited, with C-statistics around 0.54-0.62. Higher KDPI is associated with worse long-term death-censored graft outcomes, but effect magnitude varies across settings and KDPI alone has limited discriminatory ability. Local validation and periodic recalibration remain important.