Underappreciated Effects of Delayed Graft Function in Pediatric Kidney Transplantation

In kidney transplantation (KT), delayed graft function (DGF) is associated with worse outcomes. However, it is unclear what effect DGF plays in long-term survival compared to the impact of the various transplant, donor, and recipient risk factors associated with DGF. This study aims to determine the effect of DGF alone on long-term survival in pediatric deceased donor kidney transplant recipients (DDKTRs).

Using a national database, 1728 pediatric patients who received a kidney transplant between 1994 and 2009 (n = 978) and 2010 and 2022 (n = 750) were identified. Cases and controls were matched by DGF status for transplant date, cold ischemia time, distance from the transplant center, HLA mismatch level, PRA, KDPI, recipient and donor age, BMI, sex assigned at birth, and ethnicity. Kaplan-Meier curves were analyzed with a log-rank test. Pearson's chi-squared tests were used to compare survival proportions between groups at time benchmarks.

Pediatric DDKTRs with DGF had worse graft (p < 0.001) and patient (p < 0.001) survival compared to non-DGF patients in both eras. Between 1994 and 2009, graft survival rates were lower in the DGF cohort at 1 (p < 0.001), 3 (p < 0.001), 5 (p < 0.001), and 10 years (p = 0.010). Patient survival rates were lower in the DGF cohort at 1 (p = 0.017) and 5 years (p = 0.019) post-DDKT. There was no difference in 3 (p = 0.071) and 10-year patient survival rates (p = 0.141). Between 2010 and 2022, graft and patient survival rates were lower in the DGF cohort at 1, 3, 5, and 10 years (all p < 0.001). There was no difference in rates of retransplantation (p = 0.307 and p = 0.771) between groups for either era.

DGF alone is associated with worse outcomes in pediatric DDKTRs. DGF should be taken seriously, especially in cases where pediatric DDKTRs do not possess known, attributable risk factors for DGF.