Changes in Risk Factors and Outcomes Among Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function by Era

Background: In the absence of an effective therapeutic agent for preventing or treating delayed graft function (DGF) among deceased donor kidney transplant recipients (DDKTRs), proper donor and recipient selections are important to prevent detrimental outcomes associated with DGF. In this long cohort of 22 years, we assessed various risk factors for DGF and associated outcomes. Methods: DDKTRs were stratified by transplant year into four eras – E1 (2000-2005), E2 (2006-2011), E3 (2012-2017), and E4 (2018-2021). We analyzed DGF risk factors, along with one-year uncensored graft failure (UGF), death-censored graft failure (DCGF), death with a functioning graft (DWFG), and acute rejection (AR) by era. Results: A total of 3,202 DDKTRs were included in this study (E1: 844, E2: 927, E3: 930, E4: 501). DGF prevalence did not significantly differ by era. Median duration of DGF and median number of dialysis needed were lower in the recent era. In all eras, higher recipient BMI, donation after circulatory death, and donor terminal serum creatinine were risk factors for DGF, while pre-emptive transplant was protective from DGF. Other factors, such as the cold ischemia time and higher donor age, were not consistent between eras. Compared to E1, the risk of AR in the first year since transplant was significantly lower in E3 (aHR: 0.49; 95% CI: 0.33-0.74, p=0.001) and E4 (aHR: 0.11; 95% CI: 0.03-0.37, p<0.001) after adjustment for baseline characteristics. There was a trend towards decreased risk for UGF and DWFG in E2, E3, and E4 and for DCGF in E3 and E4 (Table 1). Conclusion: Some recipient and donor risk factors were consistent for DGF throughout the study period, while others differed. Likely due to appropriate management, the risk of AR associated with DGF improved in recent eras. There was also a trend of improved graft and patient survival in the recent era.Table 1. Outcomes of deceased donor kidney transplant recipients with DGF