*Purpose: The global shortage of organs and the increasing use of marginal kidneys for transplantation necessitates an accurate assessment of deceased donor kidneys. The kidney donor profile index (KDPI) is at best a moderate scoring system and though pre-implantation renal biopsies are commonly performed, the literature is inconclusive regarding the histopathological features that best predict graft outcome. This study aims to investigate the association between donor histopathological changes and graft outcome and KDPI.

*Methods: Deceased donor kidney recipients from 2013 to 2020 with an implantation renal biopsy were included. Patient’s demographic data and transplant details including graft function at 1, 3, 6 and 12 months and donor KDPI were collected. Implantation renal biopsies were analysed for the presence and severity of arteriosclerosis, interstitial inflammation, interstitial fibrosis and tubular atrophy (IFTA), glomerulosclerosis and acute tubular necrosis (ATN).

*Results: 113 patients were included in the study. The association between renal function and IFTA, interstitial inflammation and ATN were significant at 6 months whereas glomerulosclerosis was strongly associated with renal function at all time points. No association was found between renal function and arteriosclerosis. On multivariate analysis, glomerulosclerosis remained significant at all time points except at 6 months. ATN and minimal interstitial inflammation remained significantly associated with renal function at 6 months. Glomerulosclerosis and IFTA were significantly associated with KDPI with interstitial inflammation showing a trend towards significance.

*Conclusions: Glomerulosclerosis showed the most consistent and robust association with graft function whereas IFTA, interstitial inflammation and ATN were only significantly associated with graft function at 6 months. Glomerulosclerosis and IFTA were both significantly associated with KDPI.

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