Clinical and Histologic Risk Factors for the Development of Early Allograft Dysfunction in Donation After Circulatory Death Kidney Transplantation

Transplantation of kidneys from donors after circulatory death (DCD) may help address the severe shortage of donor organs. However, they remain underutilized due to concerns for increased rates of delayed graft function (DGF) and primary nonfunction (PNF), despite similar long-term patient and allograft outcomes compared to kidneys from donors after brain death (DBD). Kidneys that recover from DGF have good long-term outcomes compared to those resulting in PNF. Considering immediate graft function (IGF), DGF, and PNF as a spectrum of renal allograft injury and recovery, we analyzed donor and recipient characteristics and corresponding time-zero biopsy findings for adult DCD kidney transplants at our center from 2016 to 2021. We compared transplants resulting in DGF with subsequent allograft recovery compared to those progressing to PNF as well as to grafts that functioned immediately. We found 344 patients received DCD kidneys with 153 resulting in DGF with renal recovery by 90-days post-transplant. Excluding surgical complications, 22 patients developed PNF and required ongoing maintenance dialysis after 90-days post-transplant and 169 patients had immediate graft function. Kidney Donor Profile Index ≥85% and donor history of diabetes and hypertension were associated with PNF. Cold and warm ischemia time, donor acute kidney injury, and use of hypothermic machine perfusion were not significantly different between the groups. Formalin-fixed paraffin embedded renal allograft time-zero biopsies demonstrated that increasing severity of donor-derived vascular disease present at the time of transplant were associated with the development of early allograft failure. These findings help define clinical characteristics important in kidney allograft selection.