*Purpose: Because of organ shortage, the world facing problem, expanded criteria donor (ECD) was utilized to increase donor pool. Although long term allograft survival from ECD is inferior to transplantation from standard donor, it is still better than maintaining on dialysis. In real life, ECD may present with acute kidney injury (AKI) and some present with severe AKI. Facing with this problem, many transplant centers decide not to use these kidneys because of fearing worse transplant outcomes, resulting in high discard rate. This study is to determine the long term result of ECD with severe AKI.

*Methods: This retrospective study analysis of ECD outcomes from January 2012 to December 2019. Kidney grafts were classified as ECD without AKI (ECD-non AKI) and ECD with AKI (ECD-AKI). Severities of AKI were classified into stage 1, 2 and 3 based on change of terminal serum creatinine (Cr) from baseline by Acute kidney injury Network (AKIN) criteria. Primary outcome was 5-year allograft survival rate. Secondary outcomes were rate of delayed graft function (DGF), rate of allograft rejection and 5-year posttranspant estimated glomerular filtration rate (eGFR) calculated by CKD-EPI equation. AKI status, recipient age, donor age, DGF and allograft rejection were used in multivariate analysis to identify factors that may affect outcomes.

*Results: Of 743 DDKT recipients, 95 ECD cases were included in this study. There were 38 patients (40%) in ECD-non AKI and 57 patients (60%) in ECD-AKI group (ECD-AKIN1, 2, and 3 were 21%, 26% and 13% respectively). Mean donor Cr were progressively higher with severity of AKI (0.83 ± 0.27, 1.43 ± 0.35, 2.02 ± 0.65 and 4.24 ± 2.04 mg/dl, p < 0.01). Rate of DGF and allograft rejection were not different. Five-year graft survival rates were statistically comparable among ECD-non AKI and ECD-AKI subgroups (80.6% 73.7%, 78.3% and 100% respectively, p = 0.35). Surprisingly, 5-year eGFR was highest in ECD-AKIN3 (36.7 ± 14.5, 36.6 ± 16.1, 23.3 ± 7.1 and 52.5 ± 16.3 cc/min/1.73m² respectively, p = 0.03). Multivariate analysis showed factors associated graft loss were DGF (p=0.01) and donor-recipient age different > 10 years (p=0.38), not AKI status.

*Conclusions: : Kidney transpantation from ECD with AKI has comparable allograft survival with ECD without AKI. ECD-AKI status was not associated with inferior outcomes even with AKIN3. Use of ECD with AKI is worthwhile especially in the situation of severe organ shortage.

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