Objectives: How smoking history affects kidney allograft outcomes is unclear in the contemporary era of immunosuppression. Here, we examined a broad range of outcomes after kidney transplant, stratifying patients by smoking status documented at time of transplant, in a well-characterized clinical cohort. Results: Overall, 264 kidney allograft recipients (35.5%) had smoking exposure (current or ex-smoker) documented at time of transplant; these were more likely to be white male patients. Patients with versus without smoking exposure had higher rates of posttransplant cancer (10.2% vs 4.6%; P = .003) and cardiac events (11.7% vs 4.6%; P < .001) but lower risk of requiring hospitalization with septicemia (5.7% vs 10.0%; P = .027). Patients with versus without smoking exposure had increased rates of 1-year rejection (14.8% vs 10.4%; P = .052), thrombotic microangiopathy (4.2% vs 1.0%; P = .006), recurrent disease (4.2% vs 1.0%; P = .006), and a trend toward more acute tubular injury (16.7% vs 12.3%; P = .063). Overall, smoking exposure was associated with increased risk of death (9.5% vs 4.6%; P = .008), death-censored graft failure (13.6% vs 7.9%; P = .010), and overall graft failure (21.6% vs 11.7%; P < .001). In a Cox regression model of baseline variables, smoking exposure was independently associated with overall graft failure (hazard ratio 1.68; 95% confidence interval, 1.21-2.32; P = .002). Conclusions: Our results confirm that smoking exposure at time of kidney transplant remains associated with adverse outcomes in the contemporary era. These results reinforce the need to develop robust smoking cessation strategies to encourage kidney transplant candidates to stop smoking to improve posttransplant outcomes.

This population-cohort study suggests that deceased-donor kidneys from smokers contribute to an increased risk of death for kidney allograft recipients. These study findings imply donor smoking history should be factored into the risk stratification decision for recipient selection to optimize decision making; however, further clarification and validation of these data are warranted.

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