{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,26]],"date-time":"2026-04-26T17:35:48Z","timestamp":1777224948472,"version":"3.51.4"},"reference-count":45,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T00:00:00Z","timestamp":1775606400000},"content-version":"vor","delay-in-days":7,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Clinical Transplantation"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Efforts to expand the kidney transplant (KT) donor pool have included geographic expansion of donation. We evaluated the outcomes after KT from organs procured outside of the continental United States (US).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Adult kidney\u2010only deceased donor transplants from 2011 to 2022 in the United Network for Organ Sharing (UNOS) database were categorized by donor and recipient location (mainland to mainland US [MM], non\u2010mainland to mainland [NMM], and non\u2010mainland to non\u2010mainland [NMNM]). Recipient overall and event\u2010free survival were evaluated using time\u2010to\u2010event analysis and multivariable Cox regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      There were 163\u00a0004 (98.5%) MM, 1351 (0.8%) NMM, and 1190 NMNM (0.7%) transplants, with non\u2010mainland donors from Puerto Rico (1233), Hawaii (806), Alaska (483), Bermuda (12), and the United States Virgin Islands (USVI) (7). Non\u2010mainland donors were older (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001), had lower body mass index (BMI) (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001), were less likely to have smoked cigarettes (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001), had lower creatinine (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001), and were less likely to donate after cardiac death (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001) or utilize perfusion machines (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001) compared to MM.\u00a0 NMM transplants traveled further between donor and recipient centers (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001) and had longer cold ischemia times (CITs) (24.1 vs.\u00a0 17.2 h,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001). There was no difference in acute rejection (adjusted odds ratio [aOR] 1.14,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.59).\u00a0 NMM recipients had similar 1\u2010year (adjusted hazard ratio [aHR] = 0.87 [95% confidence interval (CI) 0.65\u20131.15],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.32) and 5\u2010year (aHR = 0.\u00a090 [95% CI 0.77\u20131.06],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.19) event\u2010free survival and improved survival at 10 years (aHR = 0.83 [95% CI 0.72\u20130.95],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.006) post\u2010transplant.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Despite longer distances and CIT, select kidneys from NM donors can be successfully transplanted with excellent long\u2010term outcomes, including improved event\u2010free survival at 10 years post\u2010transplant. Use of NM donors should be encouraged to increase rates of KT.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/ctr.70533","type":"journal-article","created":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T10:50:52Z","timestamp":1775645452000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Bridging Oceans and Distance: Excellent Long\u2010Term Outcomes in Non\u2010Mainland Kidney Transplantation"],"prefix":"10.1111","volume":"40","author":[{"given":"Binuri L.","family":"Hapuarachchy","sequence":"first","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reed T.","family":"Jenkins","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily L.","family":"Larson","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7374-2246","authenticated-orcid":false,"given":"Manuj M.","family":"Shah","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6593-3985","authenticated-orcid":false,"given":"Alice L.","family":"Zhou","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-1111-9447","authenticated-orcid":false,"given":"David J.","family":"Farhat","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yusuf","family":"Ciftci","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jessica M.","family":"Ruck","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6073-7333","authenticated-orcid":false,"suffix":"Jr","given":"Francis J.","family":"Tinney","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6457-6573","authenticated-orcid":false,"given":"Russell","family":"Wesson","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth A.","family":"King","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3762-1559","authenticated-orcid":false,"given":"Benjamin","family":"Philosophe","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6294-2800","authenticated-orcid":false,"given":"Al\u2010Faraaz","family":"Kassam","sequence":"additional","affiliation":[{"name":"Division of Transplantation Surgery Department of Surgery Johns Hopkins University School of Medicine  Baltimore Maryland USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2026,4,8]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2011.03686.x"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-024-73735-8"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14702"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajt.2024.01.012"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.tp.0000438623.89310.dc"},{"key":"e_1_2_12_7_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1507080"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.suc.2013.08.007"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajkd.2003.07.017"},{"key":"e_1_2_12_10_1","doi-asserted-by":"publisher","DOI":"10.1681\/ASN.2013070784"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.13770"},{"key":"e_1_2_12_12_1","unstructured":"New Policy Adopted to Improve Kidney Pancreas Distribution\u2014OPTN [Internet] cited September 7 2015 https:\/\/optn.transplant.hrsa.gov\/news\/new\u2010policy\u2010adopted\u2010to\u2010improve\u2010kidney\u2010pancreas\u2010distribution\/."},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.kint.2016.03.007"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2012.04259.x"},{"key":"e_1_2_12_15_1","doi-asserted-by":"publisher","DOI":"10.1038\/ki.2014.304"},{"key":"e_1_2_12_16_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000003629"},{"key":"e_1_2_12_17_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000005006"},{"key":"e_1_2_12_18_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1523-1755.2004.00416.x"},{"key":"e_1_2_12_19_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000002106"},{"key":"e_1_2_12_20_1","doi-asserted-by":"publisher","DOI":"10.2215\/CJN.13711119"},{"key":"e_1_2_12_21_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000002351"},{"key":"e_1_2_12_22_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14622"},{"key":"e_1_2_12_23_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-019-47772-7"},{"key":"e_1_2_12_24_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajt.2024.01.026"},{"issue":"2","key":"e_1_2_12_25_1","first-page":"92","article-title":"A Clinical Study on Cadaveric Kidney Donors in Puerto Rico and the Survival Outcome of the Grafts: A Retrospective Study of 187 Kidneys From 2009\u20102011","volume":"38","author":"Michelen\u2010G\u00f3mez E.","year":"2019","journal-title":"Puerto Rico Health Sciences Journal"},{"key":"e_1_2_12_26_1","doi-asserted-by":"publisher","DOI":"10.1002\/bjs.10165"},{"key":"e_1_2_12_27_1","doi-asserted-by":"publisher","DOI":"10.1111\/tri.13121"},{"key":"e_1_2_12_28_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14597"},{"key":"e_1_2_12_29_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.eclinm.2018.09.007"},{"issue":"7","key":"e_1_2_12_30_1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0236662","article-title":"Improving Outcomes for Donation After Circulatory Death Kidney Transplantation: Science of the Times","volume":"15","author":"Kok M. J. C.","year":"2020","journal-title":"PLoS ONE"},{"key":"e_1_2_12_31_1","unstructured":"USRDS [Internet] Annual Data Report cited February 2 2026 https:\/\/usrds\u2010adr.niddk.nih.gov\/."},{"key":"e_1_2_12_32_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000004280"},{"key":"e_1_2_12_33_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000005132"},{"key":"e_1_2_12_34_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41591-023-02376-7"},{"key":"e_1_2_12_35_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000005233"},{"key":"e_1_2_12_36_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-020-62979-9"},{"key":"e_1_2_12_37_1","doi-asserted-by":"publisher","DOI":"10.1097\/MOT.0b013e32835e29de"},{"issue":"3","key":"e_1_2_12_38_1","first-page":"246","article-title":"Innovative Cold Storage of Donor Organs Using the Paragonix Sherpa Pak Devices","volume":"7","author":"Anderson L. M.","year":"2015","journal-title":"Heart Lung Vessel"},{"key":"e_1_2_12_39_1","unstructured":"Paragonix Technologies Inc Paragonix KidneyVault [Internet] Accessed February 20 2026.https:\/\/www.paragonixtechnologies.com\/kidneyvault."},{"key":"e_1_2_12_40_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ekir.2023.02.1081"},{"key":"e_1_2_12_41_1","unstructured":"Scientific Registry of Transplant Recipients Organ Procurement Organization Statistics [Internet] Accessed February 20 2026.https:\/\/www.srtr.org\/reports\/opo\u2010specific\u2010reports\/."},{"key":"e_1_2_12_42_1","unstructured":"Scientific Registry of Transplant Recipients Donor Yield [Internet] Accessed February 20 2026.https:\/\/www.srtr.org\/about\u2010the\u2010data\/guide\u2010to\u2010key\u2010opo\u2010metrics\/opoguidearticles\/donor\u2010yield\/."},{"key":"e_1_2_12_43_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2008.03.120"},{"key":"e_1_2_12_44_1","doi-asserted-by":"publisher","DOI":"10.1034\/j.1399-0012.1999.t01-2-130107.x"},{"key":"e_1_2_12_45_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000000932"},{"issue":"1","key":"e_1_2_12_46_1","first-page":"28","article-title":"Hispanic Organ Donation: Impact of a Spanish\u2010Language Organ Donation Campaign","volume":"98","author":"Alvaro E. M.","year":"2006","journal-title":"Journal of the National Medical Association"}],"container-title":["Clinical Transplantation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/ctr.70533","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/ctr.70533","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/ctr.70533","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,26]],"date-time":"2026-04-26T17:09:52Z","timestamp":1777223392000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/ctr.70533"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":45,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1111\/ctr.70533"],"URL":"https:\/\/doi.org\/10.1111\/ctr.70533","archive":["Portico"],"relation":{},"ISSN":["0902-0063","1399-0012"],"issn-type":[{"value":"0902-0063","type":"print"},{"value":"1399-0012","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]},"assertion":[{"value":"2025-11-12","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-03-12","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-04-08","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70533"}}