Delayed graft function as a predictor of chronic allograft dysfunction: a 10-year follow-up study

Delayed graft function (DGF) is a common complication following kidney transplantation, yet its long-term implications for chronic allograft dysfunction (CAD) remain incompletely understood. This retrospective cohort study analyzed data from 3,850 kidney transplant recipients (KTRs)registered in the China Kidney Transplant Registry (CKTR, 2014–2024) to explore the association between DGF and CAD. DGF was defined as the requirement for dialysis within the first 7 days post-transplantation, while CAD was diagnosed based on either biopsy-confirmed interstitial fibrosis/tubular atrophy or a sustained decline in estimated glomerular filtration rate (eGFR) to < 30 mL/min/1.73 m2. Over a median follow-up of 10.2 years (calculated from the 1-year post-transplant landmark), 17.7% of recipients developed DGF, and 32.3% were diagnosed with CAD. Notably, the incidence of CAD was significantly higher in patients with DGF compared to those without (42.5% vs. 29.1%, P < 0.001). Multivariate analysis confirmed DGF as an independent predictor of CAD (adjusted hazard ratio [aHR] = 1.48, 95% CI: 1.25–1.75, P < 0.001). Stratified analyses further revealed stronger associations in high-risk subgroups, including recipients of extended-criteria donor (ECD) kidneys (aHR = 1.72, P = 0.003) and those receiving calcineurin inhibitor (CNI)-free immunosuppressive regimens (aHR = 1.65, P = 0.001). These findings identify DGF as a potential risk factor for CAD, with exploratory evidence of particularly pronounced effects in specific vulnerable populations. This underscores the need for enhanced long-term monitoring and personalized interventions in high-risk patients to optimize graft survival outcomes.