*Purpose: Delayed graft function (DGF), or acute kidney injury in the perioperative period, is associated with decreased kidney graft survival.

*Methods: As animal studies suggest that microvascular rarefaction is a key factor in the acute to chronic kidney disease transition, we assessed whether DGF is associated with increased peritubular capillary (PTC) loss. Then, we set out to determine the predictors and the impact of PTC loss in patients with DGF.

*Results: Amongst the 220 study participants, 75 experienced DGF and 145 had immediate graft function. Kidney transplant recipients with DGF exhibited greater PTC loss in the first post-transplant year than those with immediate graft function (β: 2.73% of efficient cortical area occupied by PTC, p<0.0001). PTC loss was associated with decreased renal graft function 3 years post transplant (β: -8.87 ml/min/1.73m² per standard deviation increase in PTC loss, p<0.0001). Recipient statin use at the time of transplantation (β: -0.9%, 95% CI -1.9, -0.02) and donation after cardiocirculatory arrest (β: -1.8% relative to neurological death, 95% CI -3.3, -0.2) were protective for PTC loss, while donor hypertension enhanced microvascular rarefaction in patients with DGF (β: + 1.2%, 95% CI 0.1, 2.3).

*Conclusions: Our findings support an important role for microvascular rarefaction in the acute kidney injury to chronic kidney disease transition and shed light on the variability in functional outcomes in transplant patients with DGF.

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