*Purpose: Several single-center studies have suggested no link between delayed graft function (DGF) and graft survival in recipients of donation after cardiac death (DCD) kidneys, but small studies risk type II (underpowered) error and cannot adjust for multiple risk factors. We investigated these suggestions in a large registry powered to answer this question.

*Methods: We studied 152,415 adult first-time DDKT recipients from 2010-2018 using SRTR data. We compared all-cause graft failure (ACGF), death-censored graft-failure (DCGF) and all-cause mortality (ACM) for DGF vs. non-DGF recipients of DBD and DCD grafts using Cox regression, adjusting for recipient, donor, and transplant characteristics.

*Results: DGF occurred in 23.4% of DBD recipients and 41.1% of DCD recipients. Within a year of transplant, DBD recipients with DGF had 3.06-fold higher risk of ACGF (95% confidence interval (CI) = 2.94-3.19), 4.63-fold higher risk of DCGF (95% CI= 4.38-4.88), and 2.09-fold higher risk of ACM (95% CI= 1.98-2.21) compared to those without DGF. Quite similarly, within a year of transplant, DCD recipients with DGF had 2.27-fold higher risk of ACGF (95% CI= 2.04-2.56), 3.36-fold higher risk of DCGF (95% CI= 2.89-3.91), and 1.57-fold higher risk of ACM (95% CI= 1.35-1.81) compared to those without DGF. DGF had a similar association with outcomes within 1-5, 5-10 and 10-17 year post-transplantation for DBD and DCD recipients (p>0.05) (Figure).

*Conclusions: DGF is associated with worse graft and patient survival in both DBD and DCD recipients. DCD organs should not be viewed differently in terms of DGF impact.

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