Delayed graft function in simultaneous pancreas-kidney transplantation: a marker of recipient risk, rather than graft outcomes

The long-term impact of kidney delayed graft function (DGF) following simultaneous pancreas-kidney (SPK) transplantation, and its frequency in the postkidney allocation system (KAS 250) era, remains incompletely understood. We analyzed adult SPK recipients (2014-2025) in the Scientific Registry of Transplant Recipients, stratified by DGF status, with follow-up censored at 7.5 years. Multivariable logistic regression identified predictors of DGF, and Cox proportional hazards models evaluated associations with kidney and pancreas death-censored graft survival and recipient survival. Among 5474 recipients, 472 (8.6%) developed DGF. Independent predictors included pretransplant dialysis (odds ratio, 3.98; 95% confidence interval [CI], 2.43-6.52; P < .001), longer cold ischemia time (odds ratio, 1.03 per hour; 95% CI, 1.01-1.05; P = .01), and transplantation in the post-KAS 250 era (odds ratio, 1.53; 95% CI, 1.22-1.92; P < .001). DGF was not associated with acute rejection or kidney (HR, 0.92; 95% CI, 0.62-1.37; P = .69) or pancreas graft survival (HR, 1.27; 95% CI, 0.88-1.82; P = .20). In contrast, DGF was independently associated with worse recipient survival (HR, 1.66; 95% CI, 1.24-2.21; P < .001), including in analyses conditioned on one-year pancreas and kidney graft survival (HR, 1.52; 95% CI, 1.03-2.23; P = .034). DGF represents an important marker of post-transplant risk with implications for long-term recipient outcomes.