*Purpose: Delayed Graft Function (DGF) is routinely characterized as attributing to significant morbidity and mortality among kidney transplant recipients. While there are diverse potential mechanisms for onset of DGF, the clinical implications of DGF may be varied and the opportunities for minimizing DGF in the context of deceased donor transplantation are not clear. Moreover, the causal relationship between DGF and long-term graft survival is not fully understood.

*Methods: We evaluated 210,664 deceased donor transplant recipients in the SRTR receiving a solitary deceased donor (DD) kidney transplant from 1995-2017. We evaluated secular changes in the incidence of DGF (defined as use of dialysis within one week of transplantation) and short and long-term graft survival among adult DD recipients in the United States. We evaluated changes in rates of DGF and graft survival in unadjusted logistic and survival models over time.

*Results: The incidence of DGF has remained relatively stable for the two decade study period with the highest incidence (28%) in the most recent era (2014-17). In contrast, one year graft and patient survival have shown marked improvement over the period including 53% decrease in one-year graft loss from 1995-99 to 2014-2017 (12.2% to 5.7% graft loss respectively) and a 30% decrease in five-year graft loss from 1995-99 to 2010-2013 (33.0% to 23.2% graft loss). In addition, one-year survival among patients with DGF has vastly improved over the period (75.8% to 89.0%) as compared to patients without DGF (92.0% to 96.3%). Odds and hazard ratios for DGF and short and long-term graft survival respectively displayed on Figure 1.

*Conclusions: DGF is associated with lower graft survival in the United States. However, stagnant DGF incidence over time in parallel with marked improvements in short and long term graft survival suggest that DGF may not be a primary causal factor for reduced outcomes. The varied mechanisms, etiology and management of DGF may also have changed over time. Efforts to further reduce DGF rates may not have prominent impact on further improvements in graft survival but alternatively acceptance of additional higher risk deceased donors even with elevated likelihood of DGF may provide significant survival benefits.

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