Outcomes of Dual Kidney Transplantation from Donors with High Pre-Implantation Biopsy Scores

INTRODUCTION: The persistent shortage of transplantable kidneys has increased reliance on marginal organs, yet kidneys with advanced chronic lesions on pre-implantation biopsy are frequently discarded. Dual kidney transplantation (DKT) may mitigate this risk by increasing nephron mass, but outcomes of allografts with very high histological scores remain poorly defined. We evaluated kidney transplant outcomes according to transplant type and pre-implantation Karpinski score, with particular focus on DKT using kidneys with combined Karpinski score ≥9. METHODS: We conducted a retrospective cohort study of 262 adult deceased-donor kidney transplant recipients undergoing pre-implantation biopsy at a single Italian center between 2014 and 2021. Recipients were stratified into 3 allocation groups: single kidney transplantation with Karpinski score