Uncontrolled Donation After Circulatory Death Kidney Transplantation: A Single-Center Experience in Israel with Propensity-Matched Analysis

<b>Background:</b> Uncontrolled donation after circulatory death (uDCD) remains underutilized globally, despite critical organ shortages. We report outcomes from Israel's uDCD kidney transplant program compared with the matched donation after brain death (DBD) recipients. <b>Methods:</b> This retrospective cohort study analyzed all uDCD kidney transplants performed at the Rabin Medical Center between January 2018 and December 2024, compared with DBD transplants during the same period. Propensity score matching (1:3 ratio) was performed using recipient demographics, comorbidities, and donor characteristics. Primary outcomes included delayed graft function (DGF), graft failure, and patient survival. <b>Results:</b> Among 92 kidney transplants, 21 (22.8%) were from uDCD donors. After propensity-matching (21 uDCD, 63 DBD), significant baseline differences persisted: uDCD recipients were younger (47.2 ± 11.8 vs. 57.5 ± 10.9 years, <i>p</i> < 0.001) despite a similar dialysis vintage (7.2 ± 3.2 vs. 7.7 ± 3.7 years, <i>p</i> = 0.569). Warm ischemia time was 58.5 ± 12.3 vs. 3.0 ± 0.0 min (<i>p</i> < 0.001), and cold ischemia time was longer in uDCD (13.7 ± 5.9 vs. 8.4 ± 2.5 h, <i>p</i> < 0.001). DGF occurred in 90.5% of uDCD versus 54.1% of DBD recipients (<i>p</i> = 0.006). Graft failure was markedly higher in uDCD (28.6% vs. 1.6%, <i>p</i> = 0.001), yet mortality was lower (14.3% vs. 27.9%, <i>p</i> = 0.339). After a median follow-up of 60 months (IQR 48-72) for both groups, the death-censored 5 year graft survival rate was 71.4% for uDCD versus 98.4% for DBD (<i>p</i> < 0.001). <b>Conclusions:</b> Despite higher rates of DGF and graft failure, uDCD kidney transplantation demonstrated an acceptable 5 year patient survival rate in carefully selected younger recipients. These findings support cautious expansion of uDCD programs with rigorous recipient selection criteria and realistic outcome expectations.