*Purpose: An improved understanding of the effects of cold ischemia time (CIT) on deceased donor kidney (DDK) outcomes may increase organ utilization by clarifying the detrimental impact on outcomes. We performed a paired analysis of DDKs with long CIT to measure its impact on delayed graft function (DGF) and death-censored graft survival (GS).

*Methods: Using national UNOS data, we identified 6,234 pairs (by donor) of transplanted DDKs from January 2000 to February 2020 with CIT above the US median (16 hours) and at least 5 hours apart. Among 1,955 pairs with discordant DGF status, we analyzed the impact of recipient factors and shorter versus longer CIT on DGF and 10-year GS using logistic regression and the log-rank test.

*Results: Recipients were predominantly male with a mean age of 55.4 ± 12.4 years. The kidney pairs had a median CIT difference of 10 hours between the shorter and longer CIT kidneys. The DDK with shorter CIT in the pair experienced DGF 45.3% of the time, vs 54.7% for the DDK with longer CIT. The longer CIT kidneys had an increased odds ratio for DGF compared to the shorter CIT kidneys in the pair (OR=1.44, 95% CI: 1.25-1.67, p<0.0001), but no different 10-year GS (logrank p=0.36). Kidneys that experienced DGF, however, experienced worse 10-year GS than the non-DGF group (logrank p <0.001). Among the 1,955 kidneys with shorter CIT, recipients who were male, black, had a higher body mass index (BMI), or had a longer dialysis vintage had an increased odds of DGF (Table 1).

*Conclusions: In a paired analysis of long CIT kidneys, DGF is associated with worse 10-year GS. When discordant in donor kidney pairs, DGF is likely the result of recipient factors, especially when it occurs in the kidney that experienced less CIT.

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