*Purpose: Delayed graft function (DGF) is associated with morbidity and cost after deceased donor kidney transplantation. Some data suggest that previously sensitized patients and kidneys from older donors may be more susceptible to longer cold ischemia time. Our aim was to study the association of previous sensitization, donor age, and cold ischemia time on the risk of DGF.

*Methods: We used data from the Scientific Registry of Transplant Recipients (SRTR) to identify all deceased donor kidney transplantations between 2010 and September 2018. As the primary outcome was DGF, defined by the need of dialysis during the first posttransplant week, only patients with pretransplant dialysis treatment were included (N=90,810). The effects of previous sensitization, donor age, and cold ischemia time on the risk of DGF were analyzed in multivariable models.

*Results: The frequency of DGF was 28.7% in the whole cohort, 44.5% in kidneys from DCD donors, and 25.3% in kidneys from donors after brain death (DBD) (P<0.001). The frequency of DGF was 35.0% in kidneys from expanded criteria donors (ECD) compared to 27.7% for standard criteria donors (SCD) (P<0.001). Highest frequency of DGF was seen in kidneys from expanded criteria DCD donors (55.2%), compared to 33.1% in kidneys from expanded criteria DBD donors (P<0.001). In a multivariable model, adjusted for recipient factors (age, race, gender, diabetes) and donor factors (age, gender, race, DCD status, history of hypertension or diabetes, and HLA mismatch), cold ischemia time (OR 1.02 per one hour increase), and cPRA 95-98% (OR 1.13) or cPRA≥99% (OR 1.39) compared to cPRA<80%, were independent predictors of DGF. Similarly, increased donor age was an independent predictor of DGF, but interestingly the risk of DGF associated with donor age increased linearly until the age 45 yrs, and did not increase after that (e.g. OR 1.86 for donors aged 45-49 years vs. OR 1.78 for donors aged 60-64 years, compared to donors aged <20 years). The harmful effect of cold ischemia time was not increased in highly sensitized patients (cPRA ≥99%) or in kidneys from older donors in any age category, even if only DCD donors were included in the models. On the contrary, a statistically significant interaction was observed in logistic regression with a slightly lower incremental risk associated with cold ischemia time in patients with cPRA ≥99% or donor age ≥45 yrs in the adjusted models.

*Conclusions: The risk of DGF is associated with traditional risk factors in the current era, most importantly increased cold ischemia time, but the effect of donor age was less prominent than previously reported and the risk of DGF did not increase after the donor age of 45 years. Kidneys from older donors or highly sensitized recipients were not more susceptible to the harmful effects of increased cold ischemia time.

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