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Rationale & objectiveAn average of 3,280 recovered deceased donor kidneys are discarded annually in the United States. Increased cold ischemia time is associated with an increased rate of organ decline and subsequent discard. Here we examined the effect of prolonged cold ischemia time on kidney transplant outcomes.Study designRetrospective observational study.Setting & participantsRecipients of deceased donor kidney transplants in the United States from 2000 to 2018.ExposureRecipients of deceased donor kidneys were divided based on documented cold ischemia time: ≤16, 16-24, 24-32, 32-40, and >40 hours.OutcomesThe incidence of delayed graft function, primary nonfunction, and 10-year death-censored graft survival.Analytical approachThe Kaplan-Meier method was used to generate survival curves, and the log rank test was used to compare graft survival.ResultsThe rate of observed delayed graft function increased with cold ischemia time (20.9%, 28.1%, 32.4%, 37.5%, and 35.8%). Primary nonfunction also showed a similar increase with cold ischemia time (0.6%, 0.9%, 1.3%, 2.1%, and 2.3%), During a median follow-up time of 4.6 years, 37,301 recipients experienced death-censored graft failure. Analysis based on kidney donor profile index (KDPI) demonstrated significant differences in 10-year death-censored graft survival, with a death-censored graft survival in recipients of a kidney with a KDPI 85%.LimitationsHeterogeneity of acceptance patterns among transplant centers, presence of confounding variables leading to acceptance of kidneys with prolonged cold ischemia times.ConclusionsCold ischemia time was associated with an increased risk of delayed graft function and primary nonfunction. However, the effect of increased cold ischemia time is modest and has less impact than the KDPI. Transplant programs should not consider prolonged cold ischemia time alone as a predominant reason to decline an organ, especially with a KDPI

In 2017, United Network for Organ Sharing (UNOS) established the safety net policy with set criteria for offering kidney transplantation (KT) for patients who developed end‐stage renal disease between 60 and 365 days after liver transplant (LT). We provide an update on the impact of the policy. We analyzed UNOS data of liver recipients transplanted between 1987 and 2020 who developed acute kidney injury requiring dialysis within 60 days before or after LT and subsequently listed for KT. We identified 407 patients who were listed for kidney after LT before policy and 248 patients after policy. Median waiting time to KT was shorter after policy (324 days vs. 2827 days). There was a higher proportion of candidates who were listed for subsequent KT within 1‐year after policy (94.8% vs. 63.6%). KT rate was also higher after policy (87.7 vs. 30.7 per 100 patient‐years at risk). Most importantly, we started to observe a net negative kidney utilization in end‐stage liver disease setting (i.e., summation of simultaneous liver kidney and kidney after liver transplant in the first‐year after LT has decreased from 1086 to 876 transplants in 2019). Such findings are consistent with a more efficient system and more appropriate allocation of organs. [ABSTRACT FROM AUTHOR]

Rationale & Objective: An average of 3,280 recovered deceased donor kidneys are discarded annually in the United States. Increased cold ischemia time is associated with an increased rate of organ decline and subsequent discard. Here we examined the effect of prolonged cold ischemia time on kidney transplant outcomes., Study Design: Retrospective observational study., Setting & Participants: Recipients of deceased donor kidney transplants in the United States from 2000 to 2018., Exposure: Recipients of deceased donor kidneys were divided based on documented cold ischemia time: ≤16, 16-24, 24-32, 32-40, and >40 hours., Outcomes: The incidence of delayed graft function, primary nonfunction, and 10-year death-censored graft survival., Analytical Approach: The Kaplan-Meier method was used to generate survival curves, and the log rank test was used to compare graft survival., Results: The rate of observed delayed graft function increased with cold ischemia time (20.9%, 28.1%, 32.4%, 37.5%, and 35.8%). Primary nonfunction also showed a similar increase with cold ischemia time (0.6%, 0.9%, 1.3%, 2.1%, and 2.3%), During a median follow-up time of 4.6 years, 37,301 recipients experienced death-censored graft failure. Analysis based on kidney donor profile index (KDPI) demonstrated significant differences in 10-year death-censored graft survival, with a death-censored graft survival in recipients of a kidney with a KDPI <85% of 71.0% (95% CI, 70.5%-71.5%), 70.5% (95% CI, 69.9%-71.0%), 69.6% (95% CI, 68.7%-70.4%), 65.5% (95% CI, 63.7%-67.3%), and 67.2% (95% CI, 64.6%-69.6%), compared to 53.5% (95% CI, 51.1%-55.8%), 50.7% (95% CI, 48.3%-53.1%), 50.3% (95% CI, 46.6%-53.8%), 50.7% (95% CI, 45.1%-56.1%), and 48.3% (95% CI, 40.0%-56.1%), for recipients of a kidney with a KDPI >85%., Limitations: Heterogeneity of acceptance patterns among transplant centers, presence of confounding variables leading to acceptance of kidneys with prolonged cold ischemia times., Conclusions: Cold ischemia time was associated with an increased risk of delayed graft function and primary nonfunction. However, the effect of increased cold ischemia time is modest and has less impact than the KDPI. Transplant programs should not consider prolonged cold ischemia time alone as a predominant reason to decline an organ, especially with a KDPI <85%., (© 2022 The Authors.)