The extent of glomerulosclerosis as a potential criterion for allocation of marginal kidneys to single or dual kidney transplantation

The proportion of marginal donor kidneys (MDKs) has increased worldwide, and dual kidney transplantation (DKT) has been proposed to reduce organ discard and optimize utilization. Although pre-transplant biopsy and the Remuzzi score are widely used to assess donor kidneys, it remains uncertain whether additional pathological parameters can inform clinical decision-making regarding allocation between SKT and DKT. We retrospectively analyzed deceased donor kidney transplant recipients at our center between December 2017 and December 2023. Recipients receiving DKT with donor kidney glomerulosclerosis (GS) levels of 25%–50% were included as the DKT group ( n = 56). Recipients undergoing marginal SKT with GS levels within the same range were included as the m-SKT group ( n = 84), and recipients receiving SKT with GS < 25% were included as the SKT group ( n = 168). Graft outcomes were compared among the groups. Multivariable Cox regression analyses were performed to evaluate the associations of GS and transplantation strategy with graft survival. Donor kidneys were predominantly obtained from individuals experiencing circulatory death. Mean GS levels in the DKT, m-SKT, and SKT groups were 37.5%, 31.2%, and 9.9%, respectively. Graft function in the DKT group was comparable to that in the SKT group, whereas the m-SKT group showed inferior graft function. The 5-year graft survival rate was higher in the DKT group than in the m-SKT group (91.0% vs. 75.8%) and comparable to that in the SKT group (92.9%). Multivariable Cox analysis demonstrated that GS was significantly associated with graft survival among SKT recipients, while DKT strategy remained significantly associated with favorable graft survival among recipients receiving MDKs. In the Remuzzi score 4 subgroup, higher GS levels were associated with inferior outcomes despite identical composite scores. Among MDKs with GS levels of 25%–50%, DKT was associated with favorable mid-term graft outcomes compared with m-SKT. GS may provide additional pathological information for the clinical evaluation of MDKs and may contribute to individualized allocation decisions.