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Background: This study aimed to assess the association between the percentage of glomerulosclerosis (GS) in procurement allograft biopsies from high-risk deceased donor and graft outcomes in kidney transplant recipients. Methods: The UNOS database was used to identify deceased-donor kidneys with a kidney donor profile index (KDPI) score &gt; 85% from 2005 to 2014. Deceased donor kidneys were categorized based on the percentage of GS: 0-10%, 11-20%, &gt;20% and no biopsy performed. The outcome included death-censored graft survival, patient survival, rate of delayed graft function, and 1-year acute rejection. Results: Of 22,006 kidneys, 91.2% were biopsied showing 0-10% GS (58.0%), 11-20% GS (13.5%), &gt;20% GS (19.7%); 8.8% were not biopsied. The rate of kidney discard was 48.5%; 33.6% in 0-10% GS, 68.9% in 11-20% GS, and 77.4% in &gt;20% GS. 49.8% of kidneys were discarded in those that were not biopsied. Death-censored graft survival at 5 years was 75.8% for 0-10% GS, 70.9% for &gt;10% GS, and 74.8% for the no biopsy group. Among kidneys with &gt;10% GS, there was no significant difference in death-censored graft survival between 11-20% GS and &gt;20% GS. Recipients with &gt;10% GS had an increased risk of graft failure (HR = 1.27, p &lt; 0.001), compared with 0-10% GS. There was no significant difference in patient survival, acute rejection at 1-year, and delayed graft function between 0% and 10% GS and &gt;10% GS. Conclusion: In &gt;85% KDPI kidneys, our study suggested that discard rates increased with higher percentages of GS, and GS &gt;10% is an independent prognostic factor for graft failure. Due to organ shortage, future studies are needed to identify strategies to use these marginal kidneys safely and improve outcomes.

Degree of Glomerulosclerosis in Procurement Kidney Biopsies from Marginal Donor Kidneys and Their Implications in Predicting Graft Outcomes