There may be limited clinical information relevant to assessment of kidney quality in deceased donors, and data generated in the course of donor management may not reflect baseline renal health. Therefore kidney biopsies done at the time of organ procurement are increasingly used in decisions of organ allocation. However, donor procurement kidney biopsy (PBx) as assessed by frozen section can significantly underestimate the extent of chronic renal injury as compared to permanent sections. This underestimation of chronic injury may have a negative effect on renal function outcome after transplantation.

A 61 year old male with a history of ESRD associated with HIV underwent a deceased donor transplant with a kidney from a 40 year old male with a history of DM, HgbA1c 8%, COD CVA, KDPI 71%, initial creatinine 0.8/peak 1.7 mg/dl, urine negative for protein. PBx showed 5% GS, no IFTA/AS. Recipient nadir creatinine post-transplant (PT) was 1.65 mg/dl. RBx done 4 months PT for graft dysfunction showed ACR 2A, nodular GS suggesting DN, moderate AS, mild IFTA. After rejection treatment, graft function remained impaired. RBx done 6 months PT showed BK nephropathy and worsening IFTA. Average creatinine was 3.5 mg mg/dl (eGFR 20 ml/min) 1.5 years PT.

Two patients received transplants from a deceased donor age 40s with history DM, HgbA1c 12%, KDPI 50%, COD anoxia, creatinine 1.0 mg/dl. PBx showed 6.4% GS, mild AS, no IFTA. Recipient 1 was a 65 year old man with ESRD unknown cause. RBx done 2 weeks PT for DGF showed no rejection, nodular GS suggesting DN, moderate AS, moderate IFTA. Recipient 2 was a 70 year old man with ESRD attributed to secondary FSGS. RBx done 2 weeks PT for DGF showed no rejection, ATN, nodular GS suggesting DN, moderate-severe AS, moderate IFTA. Both recipients remained on dialysis 4 months PT and were considered primary non-function.

Available deceased donor information, including renal function tests and PBx, may not be representative of donor kidney quality. Underestimation of extent of underlying kidney disease in the deceased donor significantly impacted PT outcomes in these recipients. In these examples HgbA1c alone may have been a better correlate to donor kidney quality.

Abbreviations: COD=cause of death, GS=glomerulosclerosis, AS=arterial and arteriolar sclerosis, IFTA=interstitial fibrosis and tubular atrophy, RBx=recipient renal graft biopsy, ACR=acute cellular rejection, DN=diabetic nephropathy, DGF=delayed graft function