Accepted Article Sinacore, Sinacore, This by is protectedarticle reserved. Allrights copyright. doi: 10.1111/ajt.15527 lead to differences between this version and the throughbeen the copyediting, pagination typesetting, which process, may and proofreading hasThis article been accepted publicationfor andundergone peerfull but review not has 7 6 5 4 3 2 1 2 1 donation paired kidney through transplanted kidneys donor living shipped coldest” and The “oldest Article :Original type Article DR: SEGEV DORRYL ID (Orcid 0000-0003-3205-1024) MR. ALVIN G. (OrcidTHOMAS ID :0000-0003-4911-8192) DR NIMANASSIRI (Orcid: ID 0000-0003-3447-8013) Institute of Urology Institute of MD Nima Nassiri, Author: *Corresponding Immunogenetics Center, University of California Los Angeles, Los Angeles, CA. CA. LosAngeles, LosCalifornia Angeles, of University Center, Immunogenetics DC. Institute, Washington, Transplant Georgetown Medstar NationalKidney Registry, Babylon, NY. Hill, NC. Chapel Carolina, North of Epidemiology, University of Department Surgery, Department of Johns MD. Baltimore, Hopkins University, Urology, of Department of UniversityCalifornia Los Los Angeles, CA. Angeles, CA. Los Angeles, California, Southern of Urology, University of Institute Veale L. Jeffrey Nima Nassiri, 5 Matthew Ronin, Ronin, Matthew 2 Lorna Kwan, 6 Matthew Cooper, Cooper, Matthew 2 Aswani Bolagani, Version of Record. Please Version as this cite of Record. article 3 Dorry L. Segev, L. Dorry Segev, 3,4 Alvin G. Thomas, Thomas, G. Alvin 7 J. Michael J. Michael Cecka, 5 Joseph Joseph Accepted Article This by is protectedarticle reserved. Allrights copyright. disclose. interest to of no conflicts have this manuscript of authors other The Registry. Kidney ar MR and JS Health. of Institutes National Disclosures: SRTR or the U.S. Government. and author(s) in noway be as policy should seen an by of or official interpretation the (SRTR). the of these and are of reporting theresponsibility The data interpretation Institute as contractor Registry(HHRI) for the of Transplant the Scientific Recipients Research Healthcare Hennepin the by supplied been have here data reported The by Government. the U.S. ororganizations commercialimply endorsement products names, trade of doesmention nor Services, Human and Health of the Department of policiesviews or the reflect necessarily do not and alone theauthors of responsibility the are here described analyses The Segev). (PI: Registry Kidney the National from grant a research and Institute; Blood and Lung Heart theNational from Mr. Thomas) (supporting T32HL007055 (NIDDK); Diseases and Kidney Digestive and Diabetes of Institute theNational from Segev) (PI: and K24DK101828 Segev) (PI: R01DK096008 Acknowledgements: [email protected] 818-438-7111 University California of Southern DLS reports research funding from the National Kidney Registry and Registry Kidney theNational from funding research reports DLS This work was supported in part by grants number number grants by part in supported was work This e paid, full-time employees of the employees e paid, National full-time Accepted Article This by is protectedarticle reserved. Allrights copyright. (“oldest kidneys”) weof advanced age donation evaluated the effect transplantation, donor living of segment growing onthis Toexpand (KPD). donation paired ABSTRACT BMI body index = mass rate filtration glomerular (estimated) (e)GFR = panel reactive = PRA ratio hazard HR = odds OR = ratio SRTR = Registry Scientific of Transplant Recipients National NKR = Registry Kidney failure graft DCGF = death-censored human leukocyte HLA = function graft delayed = DGF Network Transplantation and OrganProcurement = OPTN cold time ischemia = CIT KPD =kidneypaired donation Abbreviations: To date, thousands of living donor kidneys have been shipped through kidney kidney through shipped been have kidneys livingdonor of thousands To date, Accepted Article donor pool donor many on to patients the efforts thehave waiting national been made list, expand for transplantation life-saving preventing factor rate-limiting the remains availability This by is protectedarticle reserved. Allrights copyright. segment growing itslargest constituted (KPD) donation paired kidney INTRODUCTION centers. distant transplant from originating or those donors older from kidneys of utilization the surrounding concerns alleviate may findings These p=0.5,0.1). (HR=1.38,0.35, failure graft or death-censored p=0.8,0.6) (OR=0.86,1.20; function graft delayed predictive of not were time ischemia andcold age Donor 0.532). (p= coldischemia or (p=0.947) age donor and function graft delayed between associations significant nowere occurred cases.in 5.2%graft failure and 4.7% of There and function death-censored had ischemia cold times and oftransplanted kidneys 6.0% were donors of 4.1% transplants, kidney donor living shipped the2,363 Of years. post-transplant toseven up for failure graft and death-censored function were stratified by cold ischemia time (<16 or or (<65 donation of at time age by stratified were Donors 2018. May to 2008 February from database Registry Kidney National usingthe onand kidneys”) function cold and graft ischemiasurvival time(“coldest prolonged increase the living donor pool for highly sensitized patients participating in KPD. in KPD. participating patients highlysensitized for pool donor living increase the timecold (CIT) donors with and to extended ischemia solutions may be viable those 2018 marked a year of record growth in living and 2018 in a year kidneyof recordgrowth transplantation marked living 2 . Though historically used with reluctance, kidneys from advanced age advanced from kidneys with reluctance, used historically Though . ≥ 16 hours). We evaluated delayed graft graft evaluated delayed 16 hours). We ≥ 65 years) and kidneys kidneys years) and 65 ≥ 16 hours. Delayed graft graft Delayed hours. 16 1 . As organ organ As . ≥ 65 years years 65 Accepted Article association with delayed graft function graft (DGF) withassociation delayed tothe due controversial remains donors living olderadult of acceptability the this, term disadvantages of advanced of advanced age donation term disadvantages controls age-matched than higher isnot kidneys donor olderliving receiving in recipients mortality that studies suggest recent More donors. age advanced in function kidney hours, overall graft survival 10 years after transplantation exceeded 70% exceeded survivalhours, graft years transplantation overall 10 after 42-65 between ranging CIT average an with even that demonstrated colleagues This by is protectedarticle reserved. Allrights copyright. older)or age of years (65 donors adult older from donation kidney in living increase fold a3.5 been has there decade, past in the that reports (OPTN) Network and Transplantation Procurement Organ The donors. organ be viable maydonors outcomes onlong-term bearing limited may have CIT prolonged by induced DGF Furthermore, need and donors recipient obviating to travel resourcevaluable centers. for to the rejection and allograft failure in living donor recipients donor inliving failure allograft and rejection acute of incidence alower with isassociated CIT shorter that suggest studies earlier 1960s. While discussion the since of atopic been has and survival function transplanted with prolonged withCIT prolonged transplanted kidneys that demonstrate living over canbesafely donor shipped long distances and boundaries for acceptable prolonged CIT acceptable prolonged boundaries for the pushing feasible, kidneys of transportation transcontinental the made pairs has In the setting of an aging population, an increasing proportion of older adult olderadult of proportion anincreasing population, anaging of In thesetting Similar to the trend in donor age, the advent of KPD chains of living donor donor living chains of KPD of advent the age, donor in trend to the Similar 5 and improved human leukocyte antigen (HLA)-matching may offset short- mayoffset (HLA)-matching human antigen and leukocyte improved 9 . Though performed using deceased donation kidneys, Ota and Ota kidneys, donation deceased using performed Though . 3,8 , allowing for more optimized utilization of this utilization more of , allowing optimized for 7 . Historically, the effect of CIT on graft ongraft of CIT effect the . Historically, 3,4 6 . , and concerns about post-operative post-operative about and, concerns 4 , contemporary studies studies , contemporary 10 1 . . . Despite . Accepted Article This by is protectedarticle reserved. Allrights copyright. network the which Thisis data study (NKR), used from Registry National a Kidney clinical its members of for KPDs facilitates that organization 501(c) nonprofit, Registry Kidney TheNational MATERIALS AND METHODS United States. the across shipped onicebeing time spentextended that allografts donor and living living kidneys, donor of veryoldest the of recipients in KPD efficacy allograft renal programs follow prescribed OPTN protocols for the evaluation, consent, and follow- consent, evaluation, the for protocols OPTN prescribed follow programs that ensure centers transplant and transplant across kidneynetworked transplants compatible of allocation the facilitate are to theNKR of functions core The theUS. includes data on all donors, waitlist candidates, and transplant recipients in the US, in the US, recipients and transplant waitlist candidates, ondonors, all dataincludes Recipients Transplant of Registry theScientific from data used also study This The SRTRdata 2018. December system in made available release (SRTR) external Source Data National Registry of Istanbul. activities of this with study are Declarationconsistent of Helsinkithe and Declaration centers. The clinicaland transplant participating from research quarterly updates receives registry NKR The protocols. andcenter-specific with NKR concordance in transplants perform centers transplant Participating donation. living up for By reviewing the National Kidney Registry database we sought to evaluate evaluate to wesought database Registry Kidney National the By reviewing 11 . The NKR network currently is comprised of . The currently of 85 NKRis network centers within transplant comprised Accepted Article This by is protectedarticle reserved. Allrights copyright. hours eight is CIT permissible of limit upper thatthe suggested have studies Previous CIT. of 16 hours than greater or than either less of cohorts two into divided similarly were allografts Renal States. the United in to Medicare access defines age that aged or adult older65 years cohort older. A of 65cut off was years as chosen the an years and 65 than younger of group acontrol age into by classified were donors Living nephrectomy. donor the than center transplant at adifferent transplanted (SRTR). defined kidneys as Recipients shipped that werethose Transplant We of Registry Scientific data to NKR reported by linking were cross validated includingevent, collected. Specific to transplantation CIT information pertaining the were recipients and donors both for data and clinical socioeconomic, Demographic, confidentiality. patient toensure and recipients donors to both were assigned Aliases thisstudy. in inclusion for the NKR from extracted were May2018 2008 to February evaluated parameters and classifications, variable selection, Patient to the activities the of OPTN and SRTR contractors. oversight provides Services Healthand Human of Department U.S. Administration, and Services Resources Health The (9). described previously been and has (OPTN), Network andTransplantation Procurement Organ the of members by submitted of prolonged CIT. To ensure that the 16-hour cutoff would not cause CIT to fail asa tofail CIT cause not would cutoff 16-hour the that ensure To CIT. prolonged of effect the to evaluate ability our in tomaximize order limit, CIT standard doubling the outcomes, including allograft survival allograft including outcomes, thought to a with of acute no have incidence lower rejection, impact on long-term 4,12 Living donor kidney transplantations facilitated through KPD occurring from from occurring KPD through facilitated transplantations kidney donor Living . Living donor kidneys with CIT less than 8hours have historicallybeen 4 . We selected our cutoff of 16 hours by by 16hours of cutoff selected our . We

Accepted Article Adjusted odds ratios (OR) for donor age and CIT for DGF are reported, and adjusted and reported, are DGF CIT for and age donor for (OR) odds ratios Adjusted model were those with p significant at p at significant other covariate anyand themodel in was included and CIT age donor outcomes, both For related causes. up, non-transplant whichthat died those from included asyears from transplantto graft failure for those thatfailed or to time of last follow- completed DGF a DCGF and for Cox with for regression time of follow-up calculated was regression logistic analyses, multivariate For tests. Chi-square using and CIT age donor across werecompared and DGF DCGF of Incidence and CIT. age donor of categories the and by cohort entire the for were summarized compatibility, ABO and matching, HLA CIT, race, recipient and donor gender, recipient and age, donor Statistical analysis (Form 2728). andCMS SRTR reports, center transplant from was ascertained and transplantation, or re- for kidney relisting dialysis, transplantation, resumption maintenance of asthe defined DCGF urineoutput. We of regardless transplantation following This by is protectedarticle reserved. Allrights copyright. from DGF wasyearsevaluated. were ascertained donor ageand with DGF CIT and DCGF the incidence of up to post-transplant seven of associations 1).The Figure and (Supplemental differences no found significant 16hours to< 12 12hours, 8 to< 8hours, 4to< < 4hours, at (DCGF) failure graft anddeath-censored DGF of prevalence the evaluated we also variable, significant SRTR, and SRTR, Donor, recipient and transplant characteristics, including donor and recipient recipient and donor including characteristics, transplant and Donor, recipient

defined as the need for dialysis within the first post-operative week week as thewithin defined post-operative the first need for dialysis ≤ 0.05 from a forward selection process. Covariates entered into each into entered Covariates process. selection aforward from 0.05

≤ 0.20 on univariate analysis for the respective outcome. outcome. therespective for analysis univariate on 0.20

transplant center reports and and reports center transplant Accepted Article education, insurance, pre-emptive transplant status, status, and years on transplant dialysis) pre-emptive resulted education, insurance, mass index, factors body race, thesignificant adjusting model, recipient (e.g. for p on based model selection forward enter the to were identified years ondialysis and transplantation, pre-emptive hypertension, status, diabetes, insured education, college (BMI), index body mass race/ethnicity, ≥ This by is protectedarticle reserved. Allrights copyright. age donor by DGF of incidence inthe differences no significant transplantation. for centers different to were shipped kidneys donor living of (2,023/2,363) 85.6% events were transplant pre-emptive. 25.0% of (591) kidney transplantation. a previous had received recipients of (588) 47 24.9% hours. CITof amaximum hadCIT allografts transplanted of (141) 6.0% years. 74 of age donor is provided in 1. of donors Table were 4.1% years(98) with65 orolder, a maximum and CIT age donor by stratified characteristics well astransplant as and data clinical socioeconomic, demographic, recipient and Donor and evaluated. NKR database RESULTS conducted in SAS 9.4 (Cary,with NC), were for analyses statistical All survival analysis. were included recorded follow-up oneyear of witha minimum Only transplantations DCGF. for (HR) ratios hazard 16 hours (p=0.532). For multivariate analysis, donor race, recipient gender, recipient donor race, analysis, Formultivariate hours (p=0.532). 16 Overall, DGF occurred in 5.2% (124/2,363) of cases (Figure 1). There were There 1). cases(Figure of in5.2% (124/2,363) occurred Overall, DGF in the were identified transplants kidney donor living 2,363 to2018 2008 From p ≤ 0.05 considered statistically significant. significant. statistically considered 0.05 ≤ 0.20. The final multivariate regression regression multivariate Thefinal 0.20. ≥ 65 (p=0.947) or CIT ≥ 16 hours,with Accepted Article This by is protectedarticle reserved. Allrights copyright. or DCGF (p=0.902). had PRA >80). patients [PRA] reactivewere antibody 78.8% (panel (1,852/2,349) sensitized patients (497/2,349) 21.2 data. were missing sensitization patients 14 (unsensitized). and > 80(sensitized) antibody reactive panelwith patients evaluated recipients. of subset inthisDCGF There werezeroDGF or of episodes CIT. age and prolonged with donors advanced nine transplants were note,there Of 2). (Table p=0.144) (HR=0.353, CIT prolonged or p=0.487) age (HR=1.376, between DCGF associations and donor advanced significant were no There with associated statistically DCGF (HR=1.65, p=0.012). assignificantly alone education college recipient identified analysis multivariate mismatch were identified with p<=0.20 to test in the multivariate model. Final HLA zero recipient and transplant previous status, insured college education, recipient (eGFR), rate filtration glomerular estimated donor BMI, donor analysis, multivariate For shown). not (data (p=0.536) age donor adult older or (p=0.217) CIT DCGF withprolonged of probability inthe increase statistically significant (p=0.007). DGF of odds increased a2.56-fold carried notpre-emptive which were of the BMI, and status recipient (Table 2). Those transplantations insured recipient high p<0.001), race (OR=2.53, recipient African-American with associated was DGF riskof 2). Increased (Table p=0.620) (OR=1.20, orCIT p=0.756) (OR=0.86, age donor byDGF of in incidence difference significant in statistically no To evaluate the effects of sensitization on incidence of DGF and DCGF, we andDCGF, DGF of onincidence sensitization of effects the To evaluate was no there DGF, to Similar (112). was DCGF 4.74% of Overall incidence ≤ 80. Sensitized patients did not have an increased risk of DGF (p=0.966) (p=0.966) DGF of risk an increased have didnot patients 80. Sensitized ≤ 80 Accepted Article This by is protectedarticle reserved. Allrights copyright. age increases as donor transplantation living kidney riskfor mortality additional an demonstrated not studieshave long-term However, outcomes. long-term poorer cost, and and stay hospital of length increased acuterejection, DGF, of fear for CIT prolonged with allografts and donors older adult from kidneys donor living toutilize reluctant are centers Many transplant allografts. transplanted in life-years increase kidney DISCUSSION emptive. was pre- thesetransplants of One recipients. these anyof for events mortality or DCGF, DGF, nowere There respectively. hours, 39 47, and 41, of times ischemia with the were recipients we white. cold allografts, “coldest” evaluated Similarly, and all three of these None transplants unrelated caseswerepre-emptive causes. wasoccurred secondary to one mortality donated kidneys. There that recipient of oldest these amongst DCGF of episodes were no there thesecases, one of wascenters. CIT <16 hours these eachof three cases. DGF occurred infor While 74 at aged 72,73, Individuals cases. transplant old years separate and donated and did notoverlap six uniqueconstituted Table 2). These transplantations (Supplemental CIT thelongest with kidneys three and the 1) Table (Supplemental prolonged CIT prolonged deceased donor allografts, even in the setting of poor HLA matching poor HLA of even setting inthe allografts, donor deceased oldesthave donor ratesliving survival similar allografts to orbetter than any the that have found and studies allografts, donor toliving unique are findings These There is a substantial need to increase the supply of donated kidneys and to and kidneys donated of supply the increase needto a substantial There is donors living oldest with the transplantations three the weevaluated Further, 5,13 16 do not portend poorer long-term living graft function or survival. or survival. function graft living long-term poorer portend not do . A considerable body of work suggests that age suggeststhat work of body considerable A . 6,14,15 6,14,17 and and . Accepted Article This by is protectedarticle reserved. Allrights copyright. and survivability function graft of a predictor as matching HLA of importance the increasing suggested studieshave didor DCGF. DGF Though not demonstrate of 74 years two with (47 hours) coldof days andkidney the coldest nearly ischemia donor kidney no there were CIT, the oldest episodesDGF of Interestingly, or DCGF. improvement from previous reports, which cite socioeconomic and racial factors as factors racial and socioeconomic cite which reports, previous from improvement an Thisrepresents recipients. of 37% constituted Asians, and Latinos, Americans, recipient donor living of proportion highest the represent to continued recipients white while study, our In majority. agreat to minimize the risks of post-surgical complications. evaluation pre-operative thorough undergo age, should advanced of those especially donors, kidney living All CIT. with shorter allografts or donors younger cohorts of betweencontrol in co-morbidities diddifference a considerable not demonstrate analysis our donation. However, for patients ascandidates adult olderof healthiest the only approve to programs transplant of nature selective by the beexplained as defined DGF statistically incidenceor of DCGF in older significant kidneys adult donors, from nowe found Interestingly, database. NKR inthe transplants acrossliving donor all cases. of 0.8% (18/2363) only in occurring was rare, matching HLA Perfect in study. this DCGF or DGF with associated significantly were not mismatches In the nine transplants that had both advanced age donors and prolonged prolonged and donors age advanced both that had transplants nine In the Living donations have traditionally been thought to benefit white recipients to white recipients tobenefit thought been have traditionally donations Living DCGF and DGF on CIT and age donor of extremes the evaluated Our study ≥ 65 years of age, or with CIT with age,or years of 65 ≥ 16 hours. This phenomenon may partially may phenomenon 16 hours.This s, ethnic minorities comprised of African- comprised s, ethnic of minorities 18 , HLA Accepted Article This by is protectedarticle reserved. Allrights copyright. allografts donor living receiving to major impediments the scope of this study. thisstudy. of thescope the CIT of can healthis cold length of affect etiology concerns beyondThe ischemia. andrecipient or availability suchsurgeon room as operating confounding variables, and timeshipping in distances are transit affecting CIT. Indeed, onlythe variables that conclude wecannot However, and transportation. to shipping be due mayCIT of length prolonged of etiology The outcomes. andallograft DGF on and CIT age donor living of effects the investigating todate study thelargest represents transplants donor kidney Despite the database, use ofoverour study living one of 2,000 shipped study. inthis included were not laterality or transplant technology machine perfusion of use the regarding details Granular recipient. and donor between matching orHLA CIT, age, living donor of afunction as survival graft survival and graft and long-term immediate samplebetween sizeslarger ordertrends evaluate in to database, the NKR. Future studies will be designed to multi-faceteddatasets, with arestatements speculative. purely these evaluations, further without although non-compliance, medication process, or thedisease of understanding poorer care, to access including reasons, of variety a care from post-operative topoorer lead statusmay educational lower that possible is it finding, anincidental be this may Though DCGF (HR1.65). of with associated was independently education college recipient lack of analysis, multivariable Limitations of the present study included the use of only use the Limitations of the study of included present one national

19,20 . Interestingly, . Interestingly, our in Accepted Article This by is protectedarticle reserved. Allrights copyright. KPD. in participating candidates sensitized highly their for allograft or ‘colder’ ‘older’ an inaccepting centers transplant some amongst reluctance the decrease may these findings hope that failure. We graft death-censored but not function, graft delayed against protective was status emptive transplant graft failure. Pre- ordeath-censored function graft delayed with associated increased that suggest kidneys donor living shipped over2,000 of Ourfindings age ( donor advanced CONCLUSIONS KPD. in participating when hospital recipient to the donor of travel the disincentives and remove donor convenience improve kidneys to shipping will reconsider Korea and South Netherlands, the Canada, as within such an and from countries outsideallograft center, programs that national centershavein or an concerns that someaccepting transplant ‘older’ ‘colder’ alleviate will help these findings that arehopeful KPD. We through transplantation awaiting candidates highlysensitized for particularly organs quality of availability the and limiting pool donor living the restricting may be kidneys time ischemia extended age or use advanced to centers transplant amongst reluctance A ≥ 65 years) and extended ischemia time ( time extended ischemia andyears) 65 ≥ 16 hours) are not are not 16 hours) Accepted Article This by is protectedarticle reserved. Allrights copyright. 10. Ota, K. Kayler, T.R. L.K., Srinivas, & DGF Schold, J. on of CIT-induced D. Influence 9. 8. Treat, E. G. next donation--the paired L.Kidney Veale,& I. J. P. Terasaki, S., J. Connolly, 7. Relative A. Hanley,& J. R. W. Platt, X., Zhang, M., Dahhou, J., Foster,B. 6. C. Berger, J. 5. Simpkins, C.E. 4. Treat, 3. E. Means It What Summit: House Organ The A. White Chandraker, & L. T. Pruett, 2. Network. Transplantation and Organ Procurement OPTN: 1. REFERENCES kidney transplant outcomes. outcomes. kidney transplant 1175–82 (2014). step. recipients. transplant kidney young survival in graft age to and donor mismatch HLA of importance outcomes. 7, feasible? is live organ transport donor renal transplantation: outcomes. for Our Field. results and 31P-MRS. using viability testing compared with traditional living donor kidney transplants. transplants. kidney donor living with traditional compared 99–107 (2007). (2007). 99–107 N. Engl. J. Med. N. Engl. et al. et al. et

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Accepted Article This by is protectedarticle reserved. Allrights copyright. hours, 8 < to 12 12hours, to <16 hours and < 8 4to < 4hours, times of ischemia cold by stratified (DCGF) failure graft censored Supplemental Figure1: education). recipient for adjusting after model regression (Cox (CIT) time ischemia Figure 2: age. donor cold and advanced time(CIT) ischemia Figure 1: Figures Legend 20. Kumar, K. 19. Gill, J. evaluation process. process. evaluation United States. Probability of death-censored graft failure (DCGF) by donor age and cold cold ageand donor by (DCGF) failure graft death-censored of Probability Unadjusted et al. et al. The Effect of Race and Income on Living Kidney Donation in the inthe Donation Kidney Living on Income Race and of Effect The J. Am. Soc. Nephrol. Soc. Am. J.

prevalence of delayed graft f graft delayed of prevalence donor kidney the living of completion in differences Racial Prevalence of delayed graft function (DGF) and death- (DGF) function graft delayed of Prevalence Clin. Transplant.

24,

32, ≥ 1872–1879 (2013). (2013). 1872–1879 16 hours. e13291 (2018). e13291 (2018). unction (DGF) as a function of of a function as unction (DGF) AGE AGE CHARACTERISTICS RECIPIENT Median (IQR) (mL/min) eGFR CLINICAL Unknown Obese Overweight Normal Underweight Median (IQR) BMI Unknown Islander Asian/Pacific African-American Latino or Hispanic White RACE/ETHNICITY Male Female GENDER ≥ <65 Range Median (IQR) AGE CHARACTERISTICS DONOR Accepted Article 65 This by is protectedarticle reserved. Allrights copyright. Table 1: Recipient, donor and transplant-specific characteristics. characteristics. andtransplant-specific donor Recipient, 36.6 (864) 1.1 (25) 26.2 (23.3-28.9) 3.8 (90) 3.7 (87) 10.0 (237) 10.4 (245) 72.1 (1704) 37.8 (893) 62.2 (1470) 4.1 (98) 95.9 (2265) 18.0-74.0 45.0 (35.0-53.0) % (n) N=2363 97.6 (85.5-109) (85.5-109) 97.6 2.0 (48) 18.5 (437) 41.9 (989) - - 18.0-64.0 44.0 (35.0-52.0) %(n) n=2265 <65 Age Donor 98.5 (86.2-110) 98.5 (86.2-110) 2.0 (45) 18.8 (425) 41.7 (944) 36.5 (826) 1.1 (25) 26.2 (23.3-28.9) 4.0 (90) 3.8 (85) 10.3 (234) 10.5 (237) 71.5 (1619) 37.6 (852) 62.4 (1413) - - 65.0-74.0 67.0 (66.0-69.0) %(n) n=98 ≥ 82.6 (76.2-89.4) 82.6 (76.2-89.4) 3.1 (3) 12.2 (12) 45.9 (45) 38.8 (38) 0 (0) 25.9 (23.0-28.3) 0 (0) 2.0 (2) 3.1 (3) 8.2 (8) 86.7 (85) 41.8 (41) 58.2 (57) 65 4.0 (89) 96.0 (2133) 18.0-74.0 45.0 (35.0-53.0) %(n) n=2222 <16 CIT 97.6 (85.3- 109) 109) 97.6 (85.3- 2.0 (44) 19.1 (425) 41.6 (925) 36.1 (803) 1.1 (25) 26.2 (23.3-29.0) 3.8 (85) 3.6 (80) 10.0 (223) 10.1 (225) 72.4 (1609) 37.8 (841) 62.2 (1381) 6.4 (9) 6.4 (9) 93.6 (132) 21.0-70.0 43.0 (35.0-53.0) %(n) n=141 ≥ 99.0 (87.6-111) 99.0 (87.6-111) 2.8 (4) 8.5 (12) 45.4 (64) 43.3 (61) 0 (0) 25.9 (22.8-28.0) 3.5 (5) 5.0 (7) 9.9 (14) 14.2 (20) 67.4 (95) 36.9 (52) 63.1 (89) 16 Pre-emptive Transplant PRA>80% Median (IQR) Transplant NadirPost Creatinine (mg/dL) Hypertension Diabetes Induction Non-Depleting Antibody Induction Depleting Antibody CLINICAL Public Insurance College Education GENERAL Unknown Obese Overweight Normal Underweight Median (IQR) BMI Unknown Islander Asian/Pacific African-American Latino or Hispanic White RACE/ETHNICITY Male Female GENDER ≥ <65 Range Median (IQR) Accepted Article 65 This by is protectedarticle reserved. Allrights copyright.

49.6 (1172) 61.6 (1455) 3.1 (73) 29.6 (699) 31.0 (733) 33.9 (800) 2.5 (58) 26.5 (23.2-30.9) 4.1 (97) 6.4 (152) 18.2 (430) 12.4 (294) 58.8 (1390) 53.7 (1269) 46.3 (1094) 14.3 (339) 85.7 (2024) 1.0-83.0 51.0 (39.0-60.0) % (n) N=2363 25.0 (591) 21.0 (497) 1.1 (0.9-1.3) 15.8 (373) 18.8 (444) 28.9 (684) 64.1 (1515) 12.6 (285) 12.6 (285) 58.7 (1330) 53.8 (1218) 46.2 (1047) 13.1 (296) 86.9 (1969) 1.0-83.0 50.0 (38.0-59.0) %(n) n=2265 <65 Age Donor 25.3 (573) 25.3 (573) 21.3 (482) 1.1 (0.9-1.3) 15.8 (358) 18.2 (412) 28.5 (646) 64.7 (1465) 48.9 (1108) 61.8 (1399) 3.2 (72) 29.4 (666) 31.0 (702) 33.9 (768) 2.5 (57) 26.5 (23.1-30.9) 3.9 (89) 6.5 (147) 18.3 (414) 9.2 (9) 9.2 (9) 61.2 (60) 52.0 (51) 48.0 (47) 43.9 (43) 56.1 (55) 13.0-79.0 64.0 (55.0-68.0) %(n) n=98 ≥ 18.4 (18) 18.4 (18) 15.3 (15) 1.3 (1.0-1.5) 15.3 (15) 32.7 (32) 38.8 (38) 51.0 (50) 65.3 (64) 57.1 (56) 1.0 (1) 33.7 (33) 31.6 (31) 32.7 (32) 1.0 (1) 26.9 (23.9-31.1) 8.2 (8) 5.1 (5) 16.3 (16) 65 12.4 (275) 12.4 (275) 58.9 (1309) 54.0 (1200) 46.0 (1022) 14.4 (321) 85.6 (1901) 1.0-83.0 51.0 (39.0-60.0) %(n) n=2222 <16 CIT 25.1 (557) 25.1 (557) 20.8 (462) 1.1 (0.9-1.3) 15.9 (354) 18.8 (418) 29.2 (648) 64.2 (1427) 49.3 (1096) 61.7 (1370) 3.0 (67) 29.5 (655) 31.3 (696) 33.7 (749) 2.5 (55) 26.5 (23.2-30.8) 4.1 (92) 6.6 (146) 18.0 (400) 13.5 (19) 13.5 (19) 57.4 (81) 48.9 (69) 51.1 (72) 12.8 (18) 87.2 (123) 1.0-75.0 49.0 (40.0-59.0) %(n) n=141 ≥ 24.1 (34) 24.1 (34) 24.8 (35) 1.1 (0.9-1.3) 13.5 (19) 18.4 (26) 25.5 (36) 62.4 (88) 53.9 (76) 60.3 (85) 4.3 (6) 31.2 (44) 26.2 (37) 36.2 (51) 2.1 (3) 26.3 (23.1-31.4) 3.5 (5) 4.3 (6) 21.3 (30) 16 Zero HLA mismatch ABO incompatible CLINICAL ≥ <16 Range Median (IQR) CIT (hrs) CHARACTERISTICS TRANSPLANT (IQR) Median Dialysis on Years Previous Transplant Accepted Article 16 This by is protectedarticle reserved. Allrights copyright.

0.8 (18) 2.0 (48) 6.0 (141) 94.0 (2222) 0.1-47.0 8.8 (5.5-12.0) 1.3 (0.0-2.9) 24.9 (588) % (n) N=2363 5.8 (132) 5.8 (132) 94.2 (2133) 0.1-47.0 8.9 (5.6-12.0) 1.3 (0.0-2.9) 25.4 (576) %(n) n=2265 <65 Age Donor 0.8 (17) 2.1 (47) 9.2 (9) 9.2 (9) 90.8 (89) 0.4-21.7 7.2 (2.1-12.0) 1.6 (0.3-3.1) 12.2 (12) %(n) n=98 ≥ 1.0 (1) 1.0 (1) 1.0 (1) 65 - - 0.1-15.9 8.5 (5.0-11.0) 1.3 (0.0-2.9) 24.4 (543) %(n) n=2222 <16 CIT 0.8 (17) 2.0 (45) - - 16.0-47.0 17.2 (16.4-19.0) 1.3 (0.1-3.0) 31.9 (45) %(n) n=141 ≥ 0.7 (1) 0.7 (1) 2.1 (3) 16 Accepted*Referent group Dialysis on Years Recipient preemptive transplant (Yes*) (No*) Insurance Recipient (Yes*) Education College Recipient Unknown Obese Overweight Recipient BMI (NormalWeight*) Unknown Article Asian/Pacific Islander African-American (White*) Recipient Race CIT (<16hrs*) AgeDonor (<65 years old*) No No No Underweight Hispanic/Latino ≥ ≥ Yes Yes This by is protectedarticle reserved. Allrights copyright. (DCGF). failure graft death-censored and (DGF) function Table 2: 16hrs old years 65

Adjusted multivariable analysis for the incidence of delayed graft graft delayed of incidence the for analysis multivariable Adjusted 1.402 2.535 0.971 1.199 0.859 Ratio Odds DGF 1.069 2.558 1.525 2.742 2.106 1.900 1.752 0.840 0.642-3.060 1.664-3.862 0.517-1.823 0.585-2.457 0.328-2.246 CI 95% 1.019-1.121 1.290-5.072 1.010-2.305 1.060-7.091 1.270-3.493 1.139-3.170 0.501-6.125 0.255-2.767 0.0002 0.6206 0.7562 P 0.0062 0.0072 0.0448 0.0388 0.353 1.376 Ratio Hazard DCGF 1.646

0.087-1.429 0.559-3.384 CI 95% 1.118-2.423

0.1443 0.4871 P 0.0116 Accepted Article This by is protectedarticle reserved. Allrights copyright.

Accepted Article This by is protectedarticle reserved. Allrights copyright.