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Correlates of long anastomosis time and its impact on outcomes after donation after cardiac death kidney transplantation
David Cron1, Naoka Murakami2, Lingwei Xiang3, Heidi Yeh1, James F. Markmann1, Joel T. Adler1
1Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States, 2Nephrology, Brigham and Women"s Hospital, Boston, Massachusetts, United States, 3Surgery, Brigham and Women"s Hospital, Boston, Massachusetts, United States

Objective: Warm ischemia time is detrimental to kidney allograft function, especially in donation after cardiac death (DCD) kidneys. One component of this is the time required for vascular anastomoses prior to reperfusion. We studied the effect of anastomosis time (AT) on outcomes after DCD kidney transplantation.
Design: Observational study, Scientific Registry of Transplant Recipients.
Setting and Patients: All U.S. adult DCD kidney transplant recipients from 2009-2015 (N=6,658).
Main Outcome Measures: Our exposure was AT (time off ice until reperfusion, measured in quartiles, fourth vs. first compared, alpha=0.05). Outcomes included delayed graft function (DGF) and death-censored graft survival. Multivariable logistic and Cox regression quantified effect of AT on outcome, adjusting for donor and recipient factors.
Results: Median AT was 38min (IQR 17min). Cases with the longest vs. shortest AT (fourth [≥48min] vs. first quartile [≤30min]) were more likely to involve pumped kidneys (82% vs. 73%) with longer donor warm ischemia time (22.8 vs. 19.8min) and higher KDRI (0.24 vs. 0.21). Recipients with the longest AT had more peripheral vascular disease (9.5 vs. 7.5%), higher BMI (29.6 vs. 27.9), and more cold ischemia time (19.3 vs. 17.3min). Longer AT was associated with increased DGF (OR=1.2, P<0.05) and increased graft failure (HR=1.2, P=0.04). The figure shows adjusted DGF incidence (71% vs. 59%, P<0.05) and one-year graft survival (90.1% vs. 92.5%, P<0.01) in the upper vs. lower quartiles of AT.
Conclusion: Both donor and recipient factors contribute to AT, and AT≥48min is associated with DGF and worse graft survival in DCD kidney recipients. For donors/recipients where an anastomosis may be more technically challenging or time consuming, the risk of longer AT should be considered when accepting a DCD kidney.


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