Kidney biopsies are being used to evaluate marginal deceased donor organs, but, the literature on the utility of this practice remains conflicting. We re-examined this issue by performing a multivariate analysis of 597 kidney transplant recipients. The presence of moderate arteriosclerosis and/or moderate arteriolosclerosis (MA), defined as >or=25% luminal compromise, was a significant predictor of graft outcome in standard criteria donors (multivariate, P=0.01) and in expanded criteria donors (ECD) as defined by UNOS criteria (univariate P=0.02). One-, 3-, and 5-year overall allograft survival with MA was 71%, 58%, and 40%, respectively. Increasing degrees of glomerulosclerosis (GS) were associated with earlier graft failure on univariate (P=0.03) but not multivariate analysis (P=0.36). GS>20% and interstitial fibrosis>25% had a low frequency in the material reviewed, likely reflecting our organ utilization practices, and did not have a demonstrable effect on graft outcome. Clinical parameters independently associated with worse graft function were ECD status (P<0.05), retransplantation (P=0.004), recipient age (P<0.05), and delayed graft function (P<0.0001). Donor vascular disease is an independent risk factor for suboptimal graft survival. Great caution should be exercised in the decision to transplant kidneys with moderate arterial and/or arteriolar luminal narrowing.