Declining All-cause Allograft Survival in the Modern era: A 50-y Single-center Consecutive Cohort Study

Background. Kidney transplantation outcomes have improved in the short term, but long-term graft survival gains have plateaued. Aging donors and recipients with increasing comorbidities may alter contemporary allograft outcomes. Methods. We retrospectively analyzed 2076 consecutive kidney transplants performed at a single Canadian center from 1969 to 2024, representing up to 50 y of complete follow-up. All-cause graft survival (ACGS) and death-censored graft survival were compared across 5 transplant eras using era-stratified Cox regression. Results. The median recipient age increased significantly across the eras from 35 to 54 y ( P < 0.01) and the donor age from 28 to 45 y ( P < 0.01), paralleled by 3–5-fold increases in pretransplant diabetes and obesity. Death-censored graft survival improved through the early 2000s but has since plateaued, whereas ACGS declined in the modern era (2018–2024) compared with the 1998–2009 peak ( P = 0.007). Death with function accounted for >60% of graft losses in recent years, with infectious deaths rising from 21% to 45% ( P < 0.01). Increasing donor and recipient age, comorbidities, and delayed graft function independently predicted inferior survival. Conclusions. These findings reveal a reversal in ACGS gains in the contemporary era, highlighting the need for precision immunosuppression strategies tailored to the aging, comorbid transplant population.