*Purpose: The value of PBx is unclear. The aim of this study was to determine the prognostic value of chronic changes on PBx on graft survival and GFR after DDKTx.

*Methods: All DDKTx recipients transplanted at our center between 1/2013 and 8/2018 were included. Pathology data from all PBx reports read at out center was collected. A modified Remuzzi(RU) score was used to quantify the chronic changes on PBx(glomerular sclerosis, interstitial fibrosis, arterial narrowing). The low RU sum group had a sum of 0-3(low sum) and the high RU sum group had a sum of 4-8(high sum). The outcomes were graft survival and eGFR at 1 year(yr).

*Results: The cohort size was 1,198. PBx was available in 758(63.3%). The median follow up for the cohort was 3.1 years. The median number of glomeruli in the PBx was 48(IQR 30-70). There was adequate data to calculate the RU score in 704 biopsies. The median RU sum score was 2(range 0-8) and 195(22.7%) had a high sum. The median(IQR) KDPI was 78(60-90) in the high sum and 53(34-75) in the low sum(P<.0001). Graft survival was lower in the high sum group(p=0.03).

When stratified into two cohorts; KDPI>85 vs ≤85, the difference in graft survival was no longer apparent.

In a Cox model including the RU sum and the KDPI as a continuous variable, the high sum group was not a risk factor for graft survival(1.20, 95% CI 0.80-1.79). The eGFR at 1 yr was lower and the % with eGFR <30 at 1 yr was higher in the high sum group in the cohort with donor KDPI≤85. This difference was not as apparent in the cohort with donor KDPI>85 (table).

*Conclusions: Chronic changes on PBx correlated with lower mid-term graft survival and lower GFR at 1yr; however, after controlling for KDPI, RU sum no longer was a risk factor for graft survival. Our data suggests that PBx could be of value in the recipient selection for select KDPI ≤85 as a higher RU sum correlated with lower GFR at 1 yr.

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