BACKGROUND: Organ shortage leads to the increased use of expanded-criteria donor (ECD) kidneys, which contribute to a higher risk of delayed graft function (DGF) after transplantation. The aim of this study was to determine factors that may better predict the risk of DGF. METHODS: Histologic assessments of donor renal biopsy were used with other clinical variables to predict the risk of DGF after kidney transplantation. The total Banff score equaled the sum of interstitial fibrosis (CI), tubular atrophy, arteriolar hyaline thickening, fibrous intimal thickening (CV), and fraction of sclerotized glomeruli. RESULTS: In total, 126 of 344 patients developed DGF after kidney transplantation. The histologic score for CI, tubular atrophy, and CV and the total Banff score were increased in patients with DGF. Only CI and CV were independent predictors of DGF (P<0.01). A CIV score (CI+CV; odds ratio, 2.68; 95% confidence interval, 1.55-4.66; P<0.001) was superior to the combination of the total Banff score (odds ratio, 1.48; 95% confidence interval, 0.85-2.55; P=NS). A CIV score≥1, donor age more than 51 years, and anoxia donor brain injury were associated with the highest risk of DGF. A CIV<1 identified a subgroup of ECDs at a lower risk of DGF comparable with standard-criteria donors (29.3% vs. 28.4%). CONCLUSIONS: Composite CIV score better identifies ECD kidneys with a lower risk of developing DGF. Morphologic evaluation of ECD kidneys and donor characteristics may improve kidney allocation.

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