Clinical and Histopathologic Spectrum of Primary Nonfunction in Renal Allografts

Primary nonfunction (PNF) is a serious complication of renal allografts, occurring in a subset of patients with delayed graft function (DGF) who never obtain freedom from dialysis. Prior studies have examined donor and recipient variables implicated in DGF and PNF; however, data on the underlying kidney pathology are largely lacking.

Data from the Scientific Registry of Transplant Recipients (SRTR) was merged with biopsy records, and patients with a history of DGF or PNF were identified. We compared all patients with PNF (n = 61) and DGF with a biopsy within 30 days posttransplantation (n = 714) to identify donor, recipient, and histologic variables associated with PNF. Student t tests and Fisher exact tests were used for evaluation of continuous and categorical variables, respectively. Binary logistic regression was performed for more stringent assessment of PNF predictors.

PNF was significantly associated with increased donor age (P = 0.002) and terminal creatinine > 1.5 mg/dl (P = 0.005). There was no impact of recipient age, sex, race, or disease comorbidities (hypertension, diabetes, or obesity). Kidney pathology of allograft biopsies showed an increase in diagnoses of cortical necrosis (P < 0.0001), arterionephrosclerosis (P = 0.0002), oxalate nephropathy (P = 0.03), pyelonephritis (P = 0.009), and antibody-mediated rejection (ABMR) (P = 0.0008) compared with patients with DGF who did not progress to PNF.

In patients with DGF progressing to PNF compared with DGF with recovery, cortical necrosis, arterionephrosclerosis, oxalate nephropathy, and ABMR were more common. Identification of these entities on biopsy may identify patients at highest risk of graft failure.