Deceased diabetic kidneys are increasingly utilized in transplantation. The relationship of donor's history of diabetes to clinical and histological outcomes was examined. Forty-nine diabetic deceased donor kidneys (D-DM) were transplanted into 26 normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211 diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N). Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N and a 71.6% in R-DM/D-DM (p=0.008). Death-censored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N and 87.5% in R-DM/D-DM (p=0.24). Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2-3 fold increased risk of mortality. In this cohort there was no impact on death-censored graft survival of diabetic donor status. Only 6 of 26 post perfusion biopsies showed evidence of diabetic nephropathy (<IIa) and on repeat biopsies 70% showed no evidence of progression. Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucityof structural diabetic lesions and most did not show progression.