Background <p>Kidney transplantation is the preferred kidney replacement therapy for End-Stage Kidney disease (ESKD). However, organ donation challenges and the unavailability of organ transplant surgery services in many Sub-Saharan African (SSA) countries, including Rwanda, where kidney transplantation only became available in May 2023, have necessitated traveling abroad with donors for surgery. The clinical outcomes of these transplantations, particularly long-term graft and patient survival and determinants of graft failure, have not been well documented.</p> Objectives <p>This study investigated the long-term clinical outcomes of Rwandan patients who traveled abroad with donors for kidney transplantation. It evaluated the 1-, 5-, and 10-year graft and patient survival rates and identified the risk factors for graft failure and mortality. The results will be used as a benchmark for comparison with the newly launched in-country kidney transplantation program.</p> Methods <p>We conducted a retrospective cohort study of Rwandan patients who underwent kidney transplantation abroad between January 2008 and December 2021. Data were collected from patient charts, electronic medical records, and the National Medical Referral Board registry, which includes both government- and self-funded transplants. Survival rates at 1, 5, and 10&#xa0;years were estimated using Kaplan–Meier analysis, and predictors of graft failure and patient mortality were evaluated using Cox proportional hazards regression.</p> Results <p>A total of 94 patients were included, with a mean age of 40.2 (SD: 13.7). Graft survival was estimated at 86.2% at 1&#xa0;year, 74.6% at 5&#xa0;years, and 67.6% at 10&#xa0;years. Approximately 3.3% and 6.6% of the patients died with a functioning graft at 5 and 10&#xa0;years, respectively. The overall patient survival rates were 97.7%, 71.3%, and 61.0% at 1, 5, and 10&#xa0;years post-transplantation, respectively. Female patients had a significantly higher 10-year overall survival rate (82.2%) than male patients (53.3%), who had a significantly higher mortality risk (11.46-fold increase, p = 0.03). Graft failure occurred in 30.9% of the patients, with recurrent acute rejection episodes being the leading cause (72.4%). Graft survival differences were not significant between male and female patients at 1, 5, and 10&#xa0;years (male: 84.4%, 72.4%, 67.9% vs. female: 91.3%, 80.8%, and 68.5%). However, older age was associated with higher graft failure rates, and graft loss was associated with death in 51.7% (p = 0.4). In 67% of the cohort with hypertension, there was no discernible effect on graft survival (p = 0.73). Post-transplant complications, such as infections and new-onset diabetes, are common and are associated with increased mortality. Insurance type, marital status, and educational level did not impact survival outcomes; a history of previous transplants was detrimental, whereas older age (&gt; 40&#xa0;years) was not associated with worse overall survival (p = 0.406).</p> Conclusion <p>This study highlights significant disparities in kidney transplant outcomes based on sex and post-transplant complications. The higher survival rates in female patients and the substantial impact of acute rejection episodes underline the need for targeted interventions, especially in male patients and in those with a history of graft rejection. Future research should involve more extensive prospective studies to further investigate these findings and guide improvements in long-term transplantation outcomes.</p>