*Purpose: Although many centers will consider transplanting kidneys from deceased donors (DD) with mild acute kidney injury (AKI), a markedly elevated terminal serum creatinine (tSCr) level remains a major reason for kidney discard following organ recovery. The study purpose was to review retrospectively our experience with transplanting kidneys from “extreme” AKI (eAKI) DDs.

*Methods: AKI kidneys were defined by a doubling of the DD’s admission SCr level and a tSCr level >2.0 mg/dl whereas eAKI kidneys were defined by a tSCr level ≥3.0 mg/dl. Dual kidney and multi-organ transplant recipients were excluded. All patients received depleting antibody induction and triple maintenance therapy (FK, MPA, steroids).

*Results: From 1/07 to 11/21, we transplanted 236 single AKI kidneys including 100 from DDs with a tSCr level ≥3.0 mg/dl. 49 AKI DDs had a tSCr level ≥4.0 and the remaining 51 had a tSCr level between 3.0-3.9 (overall mean 4.2 mg/dl) in the eAKI group. Mean donor and recipient ages were 32.8 and 50 years, respectively. Mean KDPI was 44%. 62 patients (62%) had at least 5-year follow-up. This eAKI group was compared to 996 concurrent control patients receiving kidneys from DDs with a tSCr <1.0 mg/dl (mean donor and recipient ages 42.6 and 53 years, respectively; mean KDPI 54%, mean tSCR 0.7 mg/dl). The incidence of delayed graft function (DGF, dialysis in first week) was 51% eAKI vs 29% in controls (p<0.0001) whereas the incidence of primary nonfunction (PNF) was 1% eAKI vs 2.6% controls (p=NS). One-year patient and kidney graft survival rates (GSR) were 98% vs 95% (p=NS) and 97% vs 91% (p=0.038) in the eAKI vs control groups, respectively. There were 2 early deaths in the eAKI group (respiratory failure at 3 months, cardiac event at 5 months) and the remaining early graft loss was secondary to PNF. With a mean follow-up of 79 months, overall patient and kidney GSRs were 84% vs 74% (p=0.029) and 71% vs 62% (p=0.08) in the eAKI vs control groups, respectively. Actual 5-year death-censored kidney GSRs were 85% eAKI vs 79% in controls (p=NS).

*Conclusions: In spite of a higher incidence of DGF, patients receiving kidneys from DDs with tSCr levels ≥3.0 mg/dl have excellent medium-term outcomes compared to those receiving kidneys from DDs with tSCr levels <1.0 mg/dl. Although a selection bias may exist for AKI DDs (lower donor age and KDPI), a high tSCr level should not be considered a contraindication to transplantation.

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