*Purpose: Kidneys continue to be discarded for reasons such as surgical damage, high kidney donor profile index (KDPI), prolonged cold ischemia time, and acute kidney injury (AKI). Transplant centers need to therefore learn to optimize and utilize more organs in order to increase transplant rates. The aim of the study is to analyze outcomes of donor kidneys noted to have AKI with microthrombi present on donor biopsy.

*Methods: Our institution accepted 18 kidneys between August 2017 – March 2019 that showed an average 54% microthrombi in the host Organ Procurement Agency (OPO) biopsy (range 30%-85%). We established a protocol using Tissue Plasminogen Activator (tPA) infusion. All kidneys were rebiopsied and placed on the LifePort Kidney Perfusion Pump upon arrival. Rebiopsies confirmed microthrombi. In order to administer the tPA, we removed the kidneys from the perfusion pump and started an infusion of 1L room temperature normal saline through the renal vein by gravity. Then, we infused 50mg of tPA through the renal artery and clamped the renal vein for 15 minutes allowing tPA to penetrate the glomuleri. We placed the kidney back on the perfusion pump and open the renal vein to drain the tPA into the preservation fluid that is recirculating throughout the pump. Follow up time of recipients: between 6 months and 2 years, 7 with more than 1 year post-transplant.

*Results: The 18 kidneys came from 10 brain dead donors with acute kidney injury. Initial creatinine of the donor averaged 1.01 (0.77-1.6) and terminal creatinine averaged 3.09 (1.39-5.3). 10 kidneys were successfully transplanted and 8 were discarded due to poor pump parameters. Time on the pump at our institute was an average of 19.3 hours (15-25 hours) – Figure 1. 9 recipients (90%) showed immediate graft function and 1 (10%) showed delayed graft function; all of with functioning grafts to date (Figure 2). 1 patient died 4 months post-transplant due to respiratory failure.

*Conclusions: There is a scarcity of kidneys available in the United States for organ transplantation. About 12 people die each day waiting for a kidney transplant and about 10 kidneys are discarded daily. This study showed that some of the typically marginal kidneys can be successfully used for transplantation with donor optimization including use of medications and machine perfusion.

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