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To report real-world long-term survival of primary penetrating keratoplasty (PK) in the United States and analyze risk factors associated with failure. Retrospective longitudinal cohort study using a large commercial insurance database. Ten million patients enrolled in the database from 2011 to 2017 were identified using Current Procedural Terminology codes for PK. Kaplan-Meier survival analysis was performed to determine failure rate and risk factors impacting graft outcomes. Five hundred and ninety-six primary PKs were identified. Th