Studies have shown that comparable kidney graft survival between donors after brain death (DBD) and donors after circulatory death (DCD) overall. However, the differential risk conferred by DCD status in various subgroups is poorly understood.

METHODS: We used Cox models and SRTR data to compare all-cause graft loss between DCD and DBD in adult deceased donor kidney-only transplant (KT) recipients 2000-2014, adjusting for donor, recipient and graft characteristics. Interaction terms between DCD and other characteristics were used to study effect modification.

RESULTS: Of 120,011 KT recipients, 10.6% received DCD. Unadjusted 5-year graft loss was 29.3% in DBD and 28.8% in DCD (Figure1); adjusted HR (aHR) was _1.08 1.13 _1.18 (p<0.001).

Risk associated with DCD was consistent across subgroups in terms of recipient characteristics but amplified by prolonged cold ischemia time (CIT), regional/national sharing, and older donor age (Table1).

Based on these characteristics, we described three groups of differential DCD-associated risk (Figure2). HR of DCD was _0.95 1.06 _1.19 (p=0.3) for group 1 (DCD comparable to DBD, N=25,187), _1.00 1.07 _1.13 (p=0.04) for group 2 (DCD slightly higher risk than DBD, N=61,033), and _1.19 1.29 _1.40 (p<0.001) for group 3 (DCD higher risk than DBD, N=33,791).

CONCLUSIONS: Risk associated with DCD KT was consistent across recipient characteristics but varied by share type, CIT, and donor age. This interaction between DCD and other donor characteristics is a novel, important consideration not captured by the traditional "risk index" approach.

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