Introduction: Prolonged cold ischemia time (CIT) in the setting of donation after cardiac death (DCD), with requisite warm ischemia time (WIT), produces a 'dual hit' on the donor kidney. The study purpose was to analyze the combined effect of these 2 factors on kidney transplant (KT) outcomes. METHODS: Single center retrospective review of DCD KT recipients stratified by CIT (≤20, 20-30, 30-40, ≥40 hrs). Standardized management algorithms were used to preserve nephron function (including machine preservation) and all patients received depleting antibody induction with tacrolimus/mycophenolate ± steroids. Delayed graft function (DGF) was defined as the need for dialysis for any reason in the 1^st week post-KT. Primary non-function (PNF) was defined as failure to render the patient dialysis-free following KT. The Kidney Donor Profile Index (KDPI) scoring system was used to characterize overall donor kidney quality. RESULTS: From 2003-2016, we performed 341 DCD KTs (76 CIT ≤20, 146 CIT 20-30, 80 CIT 30-40, 39 CIT ≥40 hrs). Mean WITs (29/25/26/23 minutes) and KDPI values (57%/53%/55%/59%) were similar while mean CITs (16.6/24.8/34.4/43.1 hrs) and pump times (10.4/13.7/16.5/21.4 hrs) differed across groups (p<0.05). With mean follow-up of 4 years, patient (79%/82%/81%/82%) and kidney graft survival (GS, 63%/68%/61%/64%) rates were similar. Rates of PNF (1.3%/3.4%/11.3%/7.7%) and DGF (47%/53%/58%/77%) increased with longer CIT (p<0.05). With CITs <30 hrs, DGF did not have an adverse effect on GS (69.7% no DGF vs 63% DGF, p=0.32). However, in KTs with CITs ≥30 hrs, DGF had a marked negative effect on GS (81% no DGF vs 50% with DGF, p=0.0008). CONCLUSION: These findings suggest that more than half of DCD KT recipients experience DGF irrespective of CIT but the negative effect of DGF on GS outcomes primarily occurs when the CIT is ≥30 hours. Based on this experience, we recommend caution in using kidneys from DCD donors when the projected CIT will exceed 30 hrs.

CITATION INFORMATION: Harriman D., Rogers J., Farney A., Orlando G., Reeves-Daniel A., Gautreaux M., Doares W., Kaczmorski S., Stratta R. Does Prolonged Cold Ischemia Affect Outcomes in Donation after Cardiac Death Kidney Transplants? Am J Transplant. 2017;17 (suppl 3).

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