Introduction: The impact of prolonged cold ischemia time (CIT) on kidney grafts donated after circulatory death (DCD) remains unclear when grafts were preserved by hypothermic pulsatile machine perfusion (MP).

Materials and Methods: This single-center study compared 59 consecutive DCD kidney grafts and 118 donation after brain death (DBD) kidney grafts (1:2 matched control) transplanted from November 2004 to December 2011. After short cold storage (median 5 hours), all grafts were preserved by MP. The patients were induced with steroids, Thymoglobulin and/or IL-2 receptor antibody and maintained with tacrolimus- and mycophenolate-based immunosuppression.

Results: Demographic data were similar except for CIT (38±9 vs. 34±11 hr, P=0.02) for DCD and DBD kidneys, respectively. DCD transplants had a significantly higher incidence of delayed graft function (DGF, 31% vs. 7%, P<0.0001) and slow graft function (SGF, 54% vs. 15%, P<0.0001) as compared with DBD transplants. Overall patient survival (87% vs. 82%, P=0.76) and death-censored graft survival (80% vs. 84%, P=0.25) were not different at 5 years posttransplant between DCD and DBD transplants. When each group of patients was divided into subgroups by CIT at median value of 36 hours, DCD transplants with long CIT had more SGF than DCD transplants with short CIT (69% vs. 37%, P=0.02), while there was no significant difference between DBD transplants with long and short CIT (21% vs. 11%, P=0.13). DCD transplants with long CIT had a lower graft survival rate than DCD transplants with short CIT (69% vs. 93% at 5 years, P=0.03). A similar trend was observed between DBD transplants with long and short CIT, but it did not reach statistical significance (79% vs 87%, P=0.30).

Conclusion: When preserved by MP, DCD kidney grafts with CIT as long as 36 hours seem to provide excellent outcome. However, since DCD kidney grafts seems to be more susceptible to ischemia than DBD kidney grafts, we should maximize efforts to reduce CIT.

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