*Purpose: Our aim was to study the impact of preimplantation biopsy (Bx) findings in selecting kidneys from more marginal donors.

*Methods: This is a 2-year prospective single center observational study of all Bx done on deceased donor kidneys between 6/2019 and 6/2021. Indications for Bx included donors with severe acute kidney injury, high kidney donor profile index (KDPI) or other indicators of marginal quality. We compared Bx findings between the kidneys transplanted vs kidneys declined. We also compared recipient and donor characteristics of the entire cohort of transplanted kidneys based on Bx status. The outcomes of interest were glomerular filtration rate (eGFR) at 4 month and graft survival for the cohort based on Bx status. All continuous data is shown as mean (standard deviation).

*Results: 922 kidneys were transplanted during the study period. A total of 530 consecutive Bx were interpreted of which 235 kidneys (44.3%) were declined. The kidneys declined based on Bx findings had more chronic changes (figure 1). Among all kidneys transplanted during the study period, 295 (32.0%) had Bx and 627 were transplanted without Bx. The Table compares characteristics of the entire transplant cohort based on Bx status. The Bx cohort had several indicators of inferior donor quality including higher KDPI, donor age and donor death from cerebrovascular accident (CVA). The Bx cohort had a lower eGFR at 4 month (51.6 (19.4) vs 57.8 (20.6), p=<.001); however, there was no difference in graft survival between the cohort stratified by Bx status (figure 2).

*Conclusions: Graft survival was similar in the cohort of DDKT with Bx even though the donor quality was inferior in the Bx cohort. Bx utilization in marginal donors is helpful to guide clinical decision making specific to donor-recipient selection and to better maximize post-transplant outcomes.

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