Half of the recovered expanded criteria donor (ECD) kidneys are discarded in the United States. A new kidney allocation system offers kidneys at higher risk of discard, Kidney Donor Profile Index (KDPI) > 85%, to a wider geographic area to promote broader sharing and expedite utilization. Dual kidney transplantation (DKT) based on the KDPI is a potential option to streamline allocation of kidneys which otherwise would have been discarded. To assess the clinical utility of the KDPI in kidneys at higher risk of discard, we analyzed the OPTN/UNOS Registry that included the deceased donor kidneys recovered between 2002 and 2012. The primary outcomes were allograft survival, patient survival and discard rate based on different KDPI categories (<80%, 80-90% and >90%). Kidneys with KDPI > 90% were associated with increased odds of discard (OR = 1.99, 95% CI 1.74-2.29) compared to ones with KDPI < 80%. DKTs of KDPI > 90% were associated with lower overall allograft failure (HR = 0.74, 95% CI 0.62-0.89) and better patient survival (HR = 0.79, 95% CI 0.64-0.98) compared to single ECD kidneys with KDPI > 90%. Kidneys at higher risk of discard may be offered in the up-front allocation system as a DKT. Further modeling and simulation studies are required to determine a reasonable KDPI cutoff percentile. Dual kidney transplantation based on the Kidney Donor Profile Index is a potential option to streamline allocation of kidneys that otherwise would be discarded. © Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.