title: Prolonged warm ischemia time is associated with graft failure and mortality after kidney transplantation.
abstract: Warm ischemia time is a potentially modifiable insult to transplanted kidneys, but little is known about its effect on long-term outcomes. Here we conducted a study of United States kidney transplant recipients (years 2000-2013) to determine the association between warm ischemia time (the time from organ removal from cold storage to reperfusion with warm blood) and death/graft failure. Times under 10 minutes were potentially attributed to coding error. Therefore, the 10-to-under-20-minute interval was chosen as the reference group. The primary outcome was mortality and graft failure (return to chronic dialysis or preemptive retransplantation) adjusted for recipient, donor, immunologic, and surgical factors. The study included 131,677 patients with 35,901 events. Relative to the reference patients, times of 10 to under 20, 20 to under 30, 30 to under 40, 40 to under 50, 50 to under 60, and 60 and more minutes were associated with hazard ratios of 1.07 (95% confidence interval, 0.99-1.15), 1.13 (1.06-1.22), 1.17 (1.09-1.26), 1.20 (1.12-1.30), and 1.23 (1.15-1.33) for the composite event, respectively. Association between prolonged warm ischemia time and death/graft failure persisted after stratification by donor type (living vs. deceased donor) and delayed graft function status. Thus, warm ischemia time is associated with adverse long-term patient and graft survival after kidney transplantation. Identifying strategies to reduce warm ischemia time is an important consideration for future study.
authors.affiliation: Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada. Electronic address: ktennankore@gmail.com.
authors.forename: Karthik K
authors.initials: KK
authors.lastname: Tennankore
authors.affiliation: Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: S Joseph
authors.initials: SJ
authors.lastname: Kim
authors.affiliation: Department of Surgery, Multi-Organ Transplant Program, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Ian P J
authors.initials: IP
authors.lastname: Alwayn
authors.affiliation: Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
authors.forename: Bryce A
authors.initials: BA
authors.lastname: Kiberd
mesh_terms: D000328:Adult; D051799:Delayed Graft Function / Q000209:etiology / Q000401:mortality / Q000628:therapy; D005260:Female; D006085:Graft Survival; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D012042:Registries; D006435:Renal Dialysis; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D052096:Warm Ischemia / Q000009:adverse effects* / Q000401:mortality*; D055815:Young Adult
keywords: graft failure; survival; transplantation; warm ischemia time