Background: The limited organ supply has led to greater use of liver allografts with higher donor risk indices (DRI) and/or donated after cardiac death (DCD). DCD status has been associated with acute kidney injury after liver transplant (LT), potentially through a systemic inflammatory response related to ischemia reperfusion injury, but an association between donor quality and the outcome of end-stage renal disease (ESRD) has not been studied. Methods: Using Scientific Registry of Transplant Recipients data linked to United States Renal Data System, we assembled a national cohort of adult LT recipients from 2/2002 to 12/2010. Subjects were excluded for ESRD prior to LT, simultaneous liver-kidney transplant, or transplant using a living donor allograft. The primary outcome was ESRD (defined as dialysis or subsequent kidney transplant). We fit multivariable Cox regression models for the outcome of ESRD, adjusted for recipient and donor characteristics. The first model included total DRI (divided into quartiles); the second model included the components of DRI, including DCD, as separate variables. Results: The cohort included 40,463 LT recipients. Median age was 54 yrs (interquartile range [IQR] 48, 60), 68% were male, 9% were black, 40% had estimated GFR<60 at time of LT, 34% were hepatitis C seropositive, and 21% had diabetes. The median DRI was 1.40 (IQR 1.14, 1.72), and 1822 (5%) received DCD livers. During median follow-up of 3.93 yrs (IQR 1.85, 6.43), ESRD occurred in 2008 (5%) and death in 11,075 (27%) subjects. In multivariable Cox regression, there was a stepwise increase in the risk of ESRD with higher DRI (DRI 1.14-1.40: HR 1.18, p=0.053; DRI 1.41-1.72: HR 1.29, p=0.003; DRI 1.73-4.30: HR 1.35, p<0.001; all compared to reference DRI <1.14). Estimated GFR<60 (HR 4.47, p<0.001), diabetes (HR 2.14, p<0.001), and black race (HR 1.84, p<0.001) were the strongest recipient risk factors for ESRD. In the second modeling adjusting for DRI components separately, DCD status was the strongest donor risk factor for ESRD (HR 1.37, p=0.013). Conclusions: Higher DRI is associated with increased risk of ESRD after LT, adjusted for recipient risk factors. This association seems to be driven, in part, by DCD status. Donor quality is an important predictor of long-term renal outcomes in LT recipients.

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