*Purpose: Histopathological assessment of kidney grafts by zero-hour biopsies adds unique information concerning organ quality that is not available on clinical grounds. The most prevalent chronic lesions in zero-hour biopsies of kidney grafts is arteriosclerosis (AS). However, the long-term influence of AS remains unknown.

*Methods: A total of 1156 patients with end-stage kidney disease who underwent living kidney transplantation between 1991 and 2016 were included in this study. The patients were divided into two groups according to the findings of wedge zero-hour biopsy as following: AS(-) (n=593) and AS(+) (n=563). The end-points included patient and graft survival, biopsy-proven rejection, renal functions of both recipients and donors, and complications.

*Results: The mean donor ages in the AS(-) and AS(+) groups were 55.0 and 60.4 years old, respectively. The 10-year patient survival rates were 94.9% and 95.2%, respectively, with no significant difference (p=0.836). The 10-year non-death-censored graft survival rates were 88.0% and 84.2%, respectively, with no significant difference (p = 0.059). The AS(+) group had significantly lower 10-year death censored graft survival than that in the AS(-) group: 91.7% and 87.4%, respectively (p=0.015). The incidence of acute T-cell-mediated rejection (TCMR), active antibody-mediated rejection (ABMR), and chronic active TCMR proven by graft biopsy was not different between the two groups. However, the AS(+) group had a significantly higher incidence rate of chronic active ABMR than that in the AS(-) group (p=0.008). Both recipients and donors in the AS(+) group had significantly lower graft function than those in the AS(-) group. The incidence rate of acute and chronic tacrolimus-induced nephrotoxicity diagnosed by graft biopsy was significantly higher in the AS(+) group than that in the AS(-) group (p=0.006). The rates of recipients who had anemia after kidney transplantation were 32.5% and 40.7%, respectively. Recipients in the AS(+) group had a higher incidence rate of anemia.

*Conclusions: The transplant recipients of living kidneys with AS had significantly lower death-censored graft survival than those without AS. They had a higher incidence rate of chronic active ABMR, tacrolimus-induced nephrotoxicity, and anemia. Long-term careful observation is needed for recipients of living kidneys with AS.

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