Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation: A retrospective, single center study

doi:10.5500/wjt.v11.i4.114

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World Journal of Transplantation

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Retrospective Cohort Study

World J Transplant. Apr 18, 2021; 11(4): 114-128
Published online Apr 18, 2021. doi: 10.5500/wjt.v11.i4.114

Table 1 Preoperative characteristics of recipients with and without delayed graft function

	All patients	DGF	No DGF	P value
	n = 294	n = 79	n = 215	P value
Transplant, yr, n (%)				0.18
2016	175 (60)	52 (66)	123 (57)
2017	119 (40)	27 (34)	92 (43)
Age, yr	56 (44-64)	58 (50-63)	54 (41-64)	0.06
Male, n (%)	186 (63)	50 (63)	136 (63)	0.99
Race, n (%)				0.35
Caucasian	48 (16)	8 (10)	40 (19)
Afro-American	153 (52)	45 (57)	108 (50)
Hispanic	88 (30)	25 (32)	63 (29)
Other	5 (2)	1 (1)	4 (2)
BMI, kg/m²	28 (24-32)	29 (26-35)	27 (24-30)	0.001^a
BMI ≥ 30 kg/m²	97 (33)	37 (47)	60 (28)	0.002^a
Redo transplant, n (%)	26 (8)	4 (5)	22 (10)	0.17
Dialysis type, n (%)				0.26
Peritoneal	24 (8)	6 (8)	18 (8)
Hemodialysis	263 (90)	73 (92)	190 (88)
Pre-dialysis	7 (2)	0 (0)	7 (3)
Duration of dialysis, mo	67.4 (29.1-88.7)	67.4 (52.5-92.9)	67.1 (46.6-87.2)	0.37
Preoperative baseline laboratory
WBC, × 10³/µL	6.6 (5.5-8.2)	6.8 (5.7-8.5)	6.6 (5.4-8.1)	0.22
Hgb, g/dL	11.1 (10.2-12.1)	11.1 (10.2-12.9)	11.2 (10.1-12.2)	0.66
Hct, %	34.5 (31.0-37.6)	34.7 (31.2-37.0)	34.5 (30.9-37.8)	0.97
K⁺, mmol/L	4.7 (4.3-5.2)	4.9 (4.4-5.4)	4.7 (4.3-5.1)	0.05
HCO3^-, mmol/L	26 (23-29)	26 (23-28)	26 (23-29)	0.36
Na⁺, mmol/L	140 (138-142)	140 (138-143)	140 (138-142)	0.25
Creatinine, mg/dL	8.9 (6.7-11.2)	9.11 (7.1-11.1)	8.9 (6.7-11.2)	0.88
Medical history, n (%)
Hypertension	285 (97)	77 (97)	208 (97)	0.75
Diabetes	108 (37)	42 (53)	66 (31)	0.001^a
Dyslipidemia	159 (54)	57 (72)	102 (47)	0.001^a
CAD	67 (23)	28 (35)	39 (18)	0.002^a
Smoking	79 (27)	19 (24)	60 (28)	0.51
Preoperative medications, n (%)
ACEi/ARB	99 (34)	19 (24)	80 (37)	0.03^a
CC-blocker	134 (46)	35 (44)	99 (46)	0.79
Beta-blocker	168 (57)	47 (59)	121 (56)	0.62
Diuretic	33 (11)	12 (15)	21 (10)	0.19
Statin	107 (36)	43 (54)	64 (30)	0.001^a
Aspirin	94 (32)	35 (44)	59 (27)	0.006^a
Clopidogrel¹	22 (7)	11 (14)	11 (5)	0.01^a
Midodrine	8 (3)	2 (3)	6 (3)	0.9
Echocardiography
LV EF < 50%, n (%)	8 (3)	3 (4)	5 (2)	0.49
DD Grade 2 or 3, n (%)	44 (15)	14 (18)	30 (14)	0.42
LVH, n (%)	183 (62)	55 (70)	128 (60)	0.11
RVSP, mmHg	28 (23-34)	27 (22-34)	28 (23-33)	0.91

Values are presented as medians with 25^th and 75^th percentiles, or as numbers (n) and percentages %.

^aP < 0.05 denotes statistical significance.

¹11 patients on both aspirin and clopidogrel.

BMI: Body mass index; DGF: Delayed graft function; WBC: White blood cell count; Hgb: Hemoglobin; Hct: Hematocrit; K⁺: Potassium; NaHCO3: Sodium bicarbonate; Na⁺: Sodium; CAD: Coronary artery disease; ACEi: Angiotensin-converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; CC-blocker: Calcium channel blocker; LVEF: Left ventricular ejection fraction; DD: Diastolic dysfunction; LVH: Left ventricular hypertrophy; RVSP: Right ventricular systolic pressure.

Table 2 Intraoperative characteristics for recipients with and without delayed graft function

	All patients	DGF	No DGF	P value
	n = 294	n = 79	n = 215	P value
Surgery time, h	2.7 (2.0-3.9)	2.5 (1.8-4.4)	2.8 (2.2-3.9)	0.03^a
Warm ischemia time, min	29 (24-36)	27 (23-34)	29 (24-36)	0.08
Fluid and electrolytes
Crystalloid, L	2.0 (1.5-2.5)	2.0 (1.5-2.2)	2.0 (1.5-2.5)	0.97
Plasmalyte/Isolyte, n (%)	94 (32)	23 (29)	71 (33)	0.82
Normal saline, n (%)	161 (55)	45 (57)	116 (54)
Combined, n (%)	39 (13)	11 (14)	28 (13)
Weight based crystalloid (mL/kg)	24 (19-32)	22 (18-31)	25 (19-33)	0.11
Albumin, grams	25 (12.5-50)	25 (25-50)	25 (12.5-50)	0.66
Packed red blood cells, n (%)				0.46
None	224 (76)	60 (76)	164 (76)
1 unit	39 (13)	11 (14)	28 (13)
2 units	25 (9)	8 (10)	17 (8)
3+ units	6 (2)	0 (0)	6 (3)
Fresh frozen plasma, n (%)				0.38
None	287 (98)	79 (100)	208 (97)
1 unit	2 (1)	0 (0)	2 (1)
2+ units	5 (2)	0 (0)	5 (2)
Platelets, n (%)				0.58
None	290 (99)	79 (100)	211 (98)
1 unit	4 (1)	0 (0)	4 (2)
Estimated blood loss, mL	100 (95-200)	150 (100-300)	100 (50-200)	0.01^a
NaHCO3, mEq	50 (50-112.5)	50 (50-100)	50 (50-150)	0.76
CaCl₂, n (%)	210 71)	59 (75)	151 (70)	0.56
CaCl₂, g	1 (0.75-1.5)	1 (0.75-1.25)	1 (0.75-1.5)	0.65
Furosemide infusion, n (%)	192 (65)	44 (56)	148 (69)	0.04^a
NaHCO₃, n (%)	54 (18)	11 (14)	43 (20)	0.31
Urine output, mL	75 (15-200)	28 (5-80)	100 (20-250)	< 0.0001^a
Hemodynamics and inotropes
MAP at baseline, mmHg	109 (96-122)	107 (95-118)	112 (96-123)	0.08
Baseline MAP < 110 mmHg, n (%)	159 (54)	51 (65)	108 (50)	0.02^a
MAP 5 min post-reperfusion, mmHg	90 (81-100)	91 (79-97)	90 (82-100)	0.45
5 min post-reperfusion MAP < 100 mmHg, n (%)	220 (75)	61 (77)	159 (74)	0.61
Drop in MAP ≥ 30 mmHg from baseline -5 min post-reperfusion, n (%)	74 (25)	18 (24)	56 (26)	0.55
MAP 30 min post-reperfusion, mmHg	91 (82-100)	92 (82-101)	91 (83-99)	0.85
30 min post-reperfusion MAP < 100 mmHg, n (%)	218 (74)	54 (68)	164 (77)	0.15
Drop in MAP ≥ 30 mmHg from baseline -30 min post-reperfusion, n (%)	70 (24)	13 (16)	57 (27)	0.07
MAP 1^st post-operative, mmHg	104 (95-113)	102 (92-110)	105 (96-113)	0.09
1^st post-operative MAP < 100 mmHg, n (%)	117 (40)	35 (44)	82 (38)	0.34
Drop in MAP ≥ 30 mmHg from baseline -1^st post-operative, n (%)	27 (9)	7 (9)	20 (9)	0.9
Dopamine, n (%)	5 (2)	2 (3)	3 (1)	0.61
Ephedrine, n (%)	74 (25)	25 (32)	49 (23)	0.12
Ephedrine dose, mg	10 (5-20)	10 (5-20)	10 (5-18)	0.62
Phenylephrine, n (%)	64 (22)	25 (32)	39 (18)	0.01^a
Phenylephrine dose, mcg	200 (100-400)	200 (125-400)	200 (100-400)	0.64
Phenylephrine timing:
None, n (%)	230 (78)	54 (68)	176 (82)	0.06
Before reperfusion, n (%)	39 (14)	14 (18)	25 (12)
After reperfusion, n (%)	10 (3)	4 (5)	6 (3)
Both before and after, n (%)	15 (5)	7 (9)	8 (4)
Phenylephrine and Ephedrine, n (%)	37 (13)	16 (20)	21 (10)	0.02^a

Values are presented as medians with 25^th and 75^th percentiles, or as numbers (n) and percentages %.

^aP < 0.05 denotes statistical significance.

DGF: Delayed graft function; MAP: Mean arterial blood pressure; NaHCO3: Sodium bicarbonate; CaCl₂: Calcium chloride; OR: Operating room.

Table 3 Donor and hypothermic machine perfusion pump characteristics for recipients with and without delayed graft function

	All patients	DGF	No DGF	P value
	n = 294	n = 79	n = 215	P value
Donor characteristics
Donor kidney				0.35
Left, n (%)	136 (46%)	33 (42%)	103 (48%)
Right, n (%)	158 (54%)	46 (58%)	112 (52%)
Donor location				0.001^a
Local, n (%)	158 (54%)	27 (34%)	131 (61%)
Import, n (%)	136 (46%)	52(66%)	84 (39%)
Kidney donor profile index, %	53 (33-81)	61 (40-85)	49 (28-75)	0.006^a
Donor age, yr	44 (32-56)	49 (36-56)	42 (30-55)	0.04^a
Donor body mass index, kg/m²	27 (23-31)	28 (25-33)	26 (23-31)	0.009^a
Donation after cardiac death, n (%)	50 (17%)	23 (29%)	27 (13%)	0.001^a
Donor cause of death				0.6
Anoxia, n (%)	119 (40%)	31 (39%)	88 (41%)
Head trauma, n (%)	76 (26%)	18 (23%)	58 (27%)
Stroke, n (%)	99 (34%)	30 (38%)	69 (32%)
Donor cardiac arrest, n (%)	141 (48%)	40 (51%)	101 (47%)	0.58
Donor medical history
Hypertension, n (%)	104 (35%)	32 (41%)	72 (33%)	0.28
Diabetes, n (%)	34 (12%)	12 (15%)	22 (10%)	0.24
Coronary artery disease, n (%)	27 (9%)	16 (20%)	11 (5%)	0.001^a
Smoking, n (%)	70 (24%)	20 (25%)	50 (23%)	0.73
Heavy alcohol use, n (%)	65 (22%)	13 (16%)	52 (24%)	0.15
Admit creatinine, mg/dL	1.1 (0.9-1.4)	1.1 (0.9-1.5)	1.1 (0.9-1.30)	0.2
Terminal creatinine, mg/dL	1.0 (0.7-1.6)	1.3 (0.81-2.8)	0.9 (0.7-1.4)	0.001^a
Terminal creatinine ≥ 1.9 mg/dL	63 (21%)	31 (39%)	32 (15%)	0.001^a
Donor Biopsy: % glomerulosclerosis	3.9 (0-8.3)	4.6 (1.7-10)	3.4 (0-7.6)	0.14
HMP pump characteristics
Cold ischemia time	28.5 (21.5-34.5)	30.6 (25.8-36.4)	26.4 (21.2-33.8)	0.009^a
Cold ischemia time ≥ 26 h	172 (59%)	58 (73%)	114 (53%)	0.002^a
Cold storage time, h	10.6 (6.8-20.6)	18.4 (7.1-24.7)	9.6 (6.8-18.9)	0.002^a
Cold storage duration ≥ 16 h	120 (41%)	46 (58%)	74 (34%)	0.001^a
Total pump time, h	13.3 (8.4-19.2)	13.1 (8.2-18.9)	13.4 (8.4-19.7)	0.37
Final pump parameters
Flow, mL/min	141 (123-156)	127 (117-148)	142 (126-159)	0.001^a
Resistance, mmHg/mL/min	0.20 (0.15-0.25)	0.24 (0.16-0.29)	0.19 (0.15-0.24)	0.001^a
Systolic pressure, mmHg	34 (29-40)	35 (30-40)	33 (27-39)	0.009^a
Diastolic pressure, mmHg	24 (18-29)	26 (19-30)	23 (18-29)	0.09
Pump flow < 150 mL/min	190 (65%)	65 (82%)	125 (58%)	0.001^a
Pump resistance ≥ 0.23 mmHg/mL/min	115 (39%)	47 (59%)	68 (32%)	0.001^a

Values are presented as medians with 25^th and 75^th percentiles, or as numbers (n) and percentages (%).

^aP < 0.05 denotes significance.

DGF: Delayed graft function; HMP: Hypothermic machine perfusion.

Table 4 Postoperative characteristics for recipients with and without delayed graft function

	All patients	DGF	No DGF	P value
	n = 294	n = 79	n = 215	P value
Post-operative location, n (%)				0.95
PACU	230 (78)	62 (78)	168 (78)
ICU	64 (22)	17 (22)	47 (22)
Extubation in OR	282 (96)	74 (94)	208 (97)	0.24
Reintubation, n (%)
Within 48 h	4 (1)	3 (4)	1 (0.5)	0.06
Within 1 wk	6 (2)	4 (5)	2 (1)	0.05
Pulmonary edema, n (%)
Within 48 h	11 (4)	5 (6)	6 (3)	0.16
Within 1 wk	13 (4)	6 (8)	7 (3)	0.11
Adverse cardiac events, n (%)
Within 48 h	10 (3)	2 (3)	8 (4)	0.62
Within 1 wk	15 (5)	3 (4)	12 (6)	0.54
Within 1 mo	17 (6)	4 (5)	13 (6)	0.1
Clavien-Dindo at 1 mo, n (%)¹
None	238 (81)	54 (68)	184 (86)	0.002^a
Grade I	4 (1)	0 (0)	4 (2)
Grade II	14 (5)	6 (8)	8 (4)
Grade IIIa	19 (6)	11 (14)	8 (4)
Grade IIIb	13 (4)	4 (5)	9 (4)
Grade IVa	4 (1)	3 (4)	1 (0.5)
Grade IVb	1 (1)	1 (1)	0 (0)
Grade V	1 (1)	0 (0)	1 (0.5)
Total complications	56 (19)	25 (32)	31 (14)
Length of stay, d	6 (5-8)	8 (6-12)	6 (5-7)	0.001^a
eGFR, 6 mo, mL/min	65.3 (48.4-81.6)	50.6 (36.2-71.0)	73.3 (58.6-89.5)	0.001^a
eGFR < 60 mL/min at 6 mo, n (%)	120 (41)	51 (65)	69 (32)	0.001^a
Graft survival at 1 yr, n (%)²	283 (96%)	71 (90)	212 (99)	0.002^a
Patient survival at 1 yr, n (%)	292 (99)	79 (100)	213 (99)	0.34

Values are presented as medians with 25^th and 75^th percentiles, or as numbers (n) and percentages %.

^aP < 0.05 denotes significance.

¹Includes ultrasound evidence of 19 perinephric fluid collections not requiring intervention, and 32 perinephric fluid collections with intervention.

²4 graft failure attributed to thrombosis were due to technical difficulty: two allografts had single renal arteries and two allografts had two renal arteries, only one of which underwent arterial reconstruction in which the inferior portal artery was connected to the vein in a side-to-side anastomosis.

PACU: Post-anesthesia care unit; ICU: Intensive care unit; BP: Blood pressure; eGFR: Estimated glomerular filtration rate.

Table 5 Perioperative predictors associated with delayed graft function

	OR	95%CI	P value
Preoperative recipient risk factor
Recipient BMI ≥ 30 kg/m²	3.8	1.947-7.548	0.0001^a
Intraoperative recipient risk factor
Baseline MAP < 110 mmHg	2.2	1.098-4.326	0.0260^a
Phenylephrine usage	2.2	1.040-4.820	0.0392^a
Donor risk factors
Cold storage time ≥ 16 h	2.8	1.378-5.666	0.0044^a
Donation after cardiac death	4.4	1.872-10.225	0.0007^a
Donor with history of CAD	5.8	2.133-16.033	0.0006^a
Terminal creatinine ≥ 1.9 mg/dL	4.3	2.041-8.855	0.0001^a
HMP pump risk factor
Resistance ≥ 0.23 mmHg/mL/min	2.2	1.132-4.307	0.0201^a

^aP < 0.05 denotes significance.

OR: Odds ratio; BMI: Body mass index; MAP: Mean arterial pressure; CAD: Coronary artery disease; HMP: Hypothermic machine perfusion pump.

Citation: Mendez NV, Raveh Y, Livingstone JJ, Ciancio G, Guerra G, Burke III GW, Shatz VB, Souki FG, Chen LJ, Morsi M, Figueiro JM, Ibrahim TM, DeFaria WL, Nicolau-Raducu R. Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation: A retrospective, single center study. World J Transplant 2021; 11(4): 114-128
URL: https://www.wjgnet.com/2220-3230/full/v11/i4/114.htm
DOI: https://dx.doi.org/10.5500/wjt.v11.i4.114