*Purpose: Donation after cardio-circulatory death (DCD) and acute kidney injury (AKI) deceased donor (DD) kidneys increase the organ pool but their rates of discard and delayed graft function (DGF) remain high. Prolonged cold ischemia time (CIT) results in additive insults to the donor kidney. The study purpose was to analyze and compare the effect of these factors on kidney transplant (KT) outcomes.

*Methods: Single center retrospective review of all DCD and AKI DD KT recipients stratified by CIT (≤20, 20-30, 30-40, ≥40 hrs). AKI DD kidneys were defined by a doubling of the DD’s admission serum creatinine (SCr) level and/or a terminal SCr level >2.0 mg/dl.

*Results: Over a 13.5 year period, we performed 341 DCD and 118 AKI DD KTs including n=76 DCD/27 AKI with CI ≤20 hrs, 146/52 with CI of 20-30 hrs, 80/30 with CI 30-40 hrs, and 39/9 with CI ≥40 hrs. Mean donor ages were 41 yrs DCD/35 AKI and mean KDPIs were 55% DCD/47% AKI. The proportion of imported kidneys increased with longer CI category with both DCD and AKI DDs. Mean recipient ages were 53 yrs DCD/50 AKI and mean waiting times were 24 months DCD/22 AKI. With a mean follow-up of 5 years, actual pt (79%/82%/81%/82% DCD vs 96%/90%/90%/78% AKI) and death-censored kidney graft survival (GS, 73%/76%/69%/76% DCD vs 92%/86%/83%/86% AKI) rates, respectively, were similar within each DD category according to longer CI. Rates of PNF were 1.3%/3.4%/11.3%/7.7% DCD and 0/6%/3%/0 AKI. Rates of DGF were 47%/53%/58%/77% DCD and 30%/42%/40%/78% AKI, respectively, which increased significantly (p<0.05) with longer CI in both DD categories. In DCD KTs with CI ≥30 hrs, the presence of DGF had a marked negative effect on GS (81% no DGF vs 50% with DGF, p=.0008). In contrast, the presence of DGF did not influence outcomes in AKI DD KTs regardless of CI time.

*Conclusions: These findings suggest that more than half of DCD KT recipients experience DGF irrespective of CI but the negative effect of DGF on GS outcomes primarily occurs when the CI time is ≥30 hrs. Based on this experience, we recommend caution in using kidneys from DCD donors when the projected CI will exceed 30 hrs whereas discard of AKI kidneys because of projected long CI is not warranted.

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