*Purpose: In light of the ongoing organ shortage, dual kidney transplantation (DKT), utilizing two adult kidneys from the same donor for one recipient, has been proposed as a means to expand the available donor pool. These kidneys often come from high Kidney Donor Profile Index (KDPI) donors (KDPI >85%). Data comparing outcomes of DKT with high KDPI single kidney transplants (SKT) remains limited.

*Methods: We assessed 336 high KDPI kidney transplants performed at our center between 2003 to 2020. Pediatric high KDPI kidneys were excluded. Dual kidneys were selected based on biopsy findings of moderate-to-severe chronic changes, donor age >75 years, or kidneys coming from a small donor.

*Results: Of the 336 high KDPI kidney transplant performed, 37 (11.0%) were DKT. Recipients of DKT were older in age (median 69.0 vs 67.0, p=0.02) and more likely to be diabetic (p=0.02). Donors for DKT had a higher KDPI score (median 96.0 vs. 91.0, p<0.0001) and were older in age (p<0.0001). For recipients, there were no differences in hospital length of stay (p=0.21) or rates of delayed graft function (54.1% vs. 51.5%, p=0.77). At one-year, eGFR was higher in the DKT cohort (52.7±23.9 vs 44.0±16.7, p=0.02). Time-zero biopsies had a more favorable profile for DKT kidneys. At one-year protocol biopsies were similar between DKT and SKT with DKT having more glomerulosclerosis (p=0.03) and arterial intimal thickening (p=0.01). One-year patient survival was 93.3% for DKT and 97.0% for SKT (HR 0.8, 95% CI 0.3-2.2, p=0.74); one-year graft survival was 93.3% for DKT and 91.6% SKT (HR 0.7, 95% CI 0.3-1.9, p=0.50).

*Conclusions: Graft and patient survival rates with DKT are similar to those of SKT high KDPI kidneys despite the kidneys coming from donors with a higher KDPI score. DKT is a good option to help further utilize high KDPI kidneys and minimize discard. In our series, one-year eGFR with DKT was superior to that observed in solitary high KDPI kidneys.

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