| Summary: | <p>BACKGROUND: The prognostic Kidney Donor Risk Index (KDRI)—developed and internally validated in the US—is a widely-used tool to predict transplant outcome of a deceased donor kidney. The KDRI is currently used for longevity matching between donors and recipients in the US. METHODS: We aimed to externally validate the KDRI as proposed by Rao et al, (2009) containing 10 donor factors (KDRI<sub>donor-only</sub>) and 1 with 4 additional transplant factors (KDRI<sub>full</sub>), with stratification on recipient age and diabetes. We used the Dutch Organ Transplantation Registry to include 3201 adult recipients transplanted from 2002 to 2012. RESULTS: The median Dutch KDRI was 1.21, and comparable with the year 2012 in the US (median of 1.24). The calibration-slope was 0.98 and 0.96 for the KDRI<sub>full</sub> and KDRI<sub>donor-only</sub>, respectively, indicating that predictions of graft failure were on average similar. The discriminative ability (Harrell’s C) of the KDRI<sub>full</sub> and the KDRI<sub>donor-only</sub> at 5 years was 0.63 (95%CI 0.62-0.64), and 0.62 (95%CI 0.61-0.63), respectively. We found misspecification of 3 KDRI factors: age (p=.002), weight (p=.017), and cold ischemia time (p < 0.001). Adding the use of inotropic drugs prior to donation (p=.040), and the interaction between circulatory-death donor kidneys and prolonged cold ischemic time ( > 24h <i>vs</i> 12h, p=.059) could improve predictive ability. CONCLUSIONS: The KDRI performs equal in the Dutch population. Discriminative ability of the KDRI indicates limited clinical use for adequate individualized decisions. An updated KDRI may contribute to a standardized policy meeting the growing demand of donor kidneys in the Eurotransplant region.</p>
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