Background Deceased donor kidneys with acute kidney injury (AKI) are often discarded because of concerns about inferior transplant outcomes. A means of grading the quality of such kidneys is the performance of procurement biopsies. Methods This is a retrospective study of 221 brain death donors with marginal kidneys transplanted in 223 recipients in Germany. Marginal kidneys were defined as kidneys with procurement biopsies done exceptionally to assess suitability for transplantation in otherwise potentially discarded organs. The impact of deceased donor AKI on patient survival and death-censored graft survival at 1, 3 and 5 years and graft function at 1 and 3 years after transplantation was investigated. Results Recipients of kidneys with stage 3 AKI had a greater incidence of delayed graft function [DGF; ORStage 1: 1.435 (95% CI 0.438–0.702), ORStage 2: 2.463 (95% CI 0.656–9.245), ORStage 3: 4.784 (95% CI 1.421–16.101)] but a similar graft and patient survival compared to recipients of donors without AKI and with AKI stage 1 and 2 as well. The coexistence of recipient DGF and donor AKI was associated with the lowest graft survival and function rates. Conclusion The transplantation of deceased donor marginal kidneys with AKI confers a higher risk for DGF but is associated with acceptable graft and patient outcomes, which do not differ in comparison with marginal donor kidneys without AKI. Graft prognosis is especially poor if donor AKI and recipient DGF concur. Donor AKI was a risk factor independent of the histological lesions of procurement biopsies.

Introduction Predicting outcome after transplantation of marginal kidneys is a challenging task. Donor creatinine or estimated glomerular filtration rate (eGFR) are integral components of the respective risk scores. However, there is uncertainty on which of their values obtained successively during procurement is the most suitable. Material and methods This is a retrospective study of 221 adult brain death donors with marginal kidneys, transplanted in 223 recipients. We applied logistic regression analysis to investigate the association between initial (at hospital admission), nadir (lowest), zenith (highest) and terminal (at recovery) donor eGFR with primary non‐function (PNF), delayed graft function (DGF), 3‐ and 12‐month graft function and 1‐ and 3‐year patient‐ and death‐censored graft survival. Results In the multivariate analysis, admission, terminal, and the lowest donor eGFR could most accurately predict DGF. The respective ORs [95% CI] were: 0.875 [0.771–0.993], 0.818 [95% CI: 0.726–0.922] and 0.793 [0.689–0.900]. Although not being significant for DGF (OR 0.931 [95% CI: 0.817–1.106]), the highest eGFR was the best predictor of 3‐month graft function (adjusted b coefficient 1.161 [95% CI: 0.355–1.968]). Analysis of primary nonfunction showed that determination of initial and the highest eGFR proved to be the best predictors. The respective ORs [95% CI] were: 0.804 [0.667–0.968] and 0.750 [0.611–0.919]. There were no differences in the risk associations of each of the four eGFR recordings with patient‐ and graft survival. Conclusion The various eGFR recordings determined during the procurement process of marginal donors can predict PNF, DGF and 3‐ and 12‐month graft function. Regarding short‐term patient‐ and graft survival, there appears to be impacted by recipient factors rather than donor kidney function.