INTRODUCTION: Hypotension is a frequent complication of patients who are on chronic maintenance hemodialysis. Midodrine is an alpha-1 adrenergic agonist used to treat patients on hemodialysis who have chronic hypotensiom. The aim of our study was to evaluate if patients who required midodrine for hypotension had inferior outcomes compared to those who did not require midodrine. METHODS: All kidney transplants performed at The Ohio State University Wexner Medical Center between January 2015 and January 2021 were analyzed. Patients that had a dual solid organ transplant that included a kidney transplant were excluded from our study. Patients were divided into two groups based on midodrine use. The main outcomes of interest were graft and patient survival at 1-year. RESULTS: A total of 1538 kidneys were transplanted during the study period. A total of 1070 were recipients of deceased donor kidney transplants, 468 were recipients of living donor kidney transplants. In the deceased donor group the estimated glomerular filtration rate was higher in the non-midodrine patients compared to the midodrine group and this difference was statistically significant. Graft survival at 1 year was higher in the non-midodrine group (96% vs 79% P, .0001 OR 6.6). Patient survival at 1-year was also higher in the non-midodrine group (97% vs 86%, P = .0002, OR 6.3). Time to graft failure and patient death was faster in the midodrine group (P <
.0001 for both). CONCLUSION: The need for Midodrine to maintain blood pressure before kidney transplantation can serve as a marker for inferior graft and patient outcomes at 1-year. Additional studies with more data are needed to further support this theory and adjust for confounding effects.