*Purpose: Several studies have shown good outcomes with transplanting kidneys from deceased donors with AKI; however, the impact of having elevated initial donor creatinine has not been studied. Transplant centers are reluctant to use kidneys from Donors with an elevated initial serum creatinine due to concern for poor outcomes. Our hypothesis is that outcomes after transplanting kidneys from carefully selected donors with severe AKI and elevated initial creatinine are non inferior. We aim to look at the graft and patient outcomes of AKIN 3 donor kidneys with initial or admit creatinine ≥2.0 when compared to AKIN 3 donors with an admit creatinine < 2.0.

*Methods: We included all deceased donor kidney transplants done at our center from 2008 to 2019. We excluded combined simultaneous extra renal organ transplant recipients. The donor AKI was classified using the AKIN staging criteria using serum creatinine criteria using data from DonorNet. We selected all recipients of AKIN3 donor kidneys and we divided the study group based on donor initial creatinine ≥2. Preimplantation biopsies were reviewed by our surgical pathologists, and kidneys with cortical necrosis >10% or mild chronic changes were discarded. Protocol biopsies were performed at 4 months and 1 year.

*Results: We identified 683 (34.5%) donors with AKIN 3, out of which 156 (22.8%) were identified to have initial creatinine ≥2. Recipient age, gender, prevalence of diabetes and dialysis were similar in both groups. There were younger donors in the cohort with initial creatinine ≥2 (30.9 vs 37.4 p <0.001), which was also reflected in the KDPI (35.0 vs 52.5 p=<0.001). More female donors were present in the group with creatinine <2 (38.0 vs 16 p=<0.001). There was no statistical significance in DCD donors in the 2 groups. DGF rates were higher in the group with initial Cr ≥2 (85.3 vs 77.6%, p=0.03). CIT was similar in both the groups. There was no difference in the death censored graft survival, acute rejection and primary non-function between the 2 groups at 1 year. Estimated GFR was higher in donors with initial Cr ≥ 2 at both 4 months (62.4 vs 54.8 ml/min/1.73 m², p=0.0001) and 1 year (64.6 vs 58.6ml/min/1.73m² p=0.0086). There were less chronic changes noted on the 1 year protocol biopsy in the group with Cr ≥2.

*Conclusions: With careful selection, AKIN3 donors with initial Cr≥2 have similar 1 year graft outcomes when compared to AKIN3 donors with initial creatinine <2.0. The favorable GFR and biopsy findings at 1 year are probably related to donor factors.

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