*Purpose: Our aim was to determine outcomes with transplanting kidneys from deceased donors with severe acute kidney injury requiring acute renal replacement therapy.

*Methods: We included all patients who received deceased donor kidney transplant during 2008 to 2019. We compared the graft survival, estimated glomerular filtration rate (eGFR) and findings on surveillance biopsy in three groups of deceased donor kidneys: AKIN3 with RRT, AKIN3 without RRT, and <85% KDPI donors without AKI (AKIN 0).

*Results: There were 172 recipients who received a kidney from donors with Acute Kidney injury stage 3 (AKIN3) requiring renal replacement therapy (RRT). We compared the study group to 528 recipients who received a kidney from donors with AKIN stage 3 not on RRT and 463 recipients who received Kidney Donor profile Index (KDPI)<85% AKIN stage 0 kidney. The study group donors were younger (p <0·001), and had lower KDPI (p <0·001) compared to the two control groups. The rate of Delayed Graft Function (DGF) was 91% in the AKIN 3 RRT compared to 76% in AKIN 3 no RRT group and 41% in the KDPI<85% AKIN 0 group (p=<0·001). Despite higher DGF, length of hospital stay and acute rejection within one year were similar between the groups. Primary graft failure was rare. Estimated GFR at 4 months, 1 year and 3 years were similar across the three groups. Death censored graft survival at 3 years was 93·5% in AKIN3-RRT group, 95% in the AKIN3 no RRT, and 91·7% in KDPI<85%AKIN0 (p=0·549). Interstitial fibrosis and tubular atrophy (IFTA) score >2 on protocol biopsy at 4 months and 1 year was similar across the three groups.

*Conclusions: Transplanting selected kidneys from deceased donors with AKIN3 requiring RRT is safe and has excellent outcomes.

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