Effect of Kidney Shipping and Prolonged Cold Ischaemia Time on Kidney Paired Donation and Living Donor Kidney Transplantation: A Structured Narrative Review

Living donor kidney transplantation has traditionally been carried out within a single centre, keeping cold ischaemia time very short. The growth of kidney paired donation, which frequently matches donors and recipients across different centres, has made organ shipping and substantially longer cold storage routine, raising the question of whether living donor kidneys remain resilient under conditions known to injure deceased donor organs. This structured narrative review brings together the contemporary evidence on shipping and prolonged cold ischaemia in adult living donor transplantation, with particular attention to paired exchange, a context not previously examined in a dedicated synthesis. The evidence points to a consistent but modest relationship between longer cold ischaemia and delayed graft function, while the absolute risk stays low and longer-term graft and patient outcomes are largely preserved, albeit on the basis of observational data alone. These findings support current paired donation and shipping practices, including long-distance transport. Cold ischaemia time should nonetheless be minimised wherever practical, particularly for older donors and highly sensitised recipients, through matching algorithms that account for cold ischaemia time, selective donor travel, and machine perfusion when prolonged storage is anticipated.