Sanjay KOLTE, Pranjal KASHIV, Akshay KRIPLANI, Chandrakant MUNJEWAR, Amol BHAWANE, Prakash KHETAN, Ashwini Kumar KHANDEKAR, Nishant DESHPANDE, Amit PASARI, Manish BALWANI
Experimental and Clinical Transplantation - 2026;24(9):707-715
Objectives: Prolonged cold ischemia is a principal modifiable determinant of delayed graft function after deceased donor kidney transplant. In conventional multiorgan procurement, kidneys are removed last, prolonging ischemic exposure, a problem magnified in resource-constrained programs. We assessed whether retrieving 1 kidney first, from a heart-beating donor before aortic cross-clamping, improves early graft outcomes. Materials and Methods: This retrospective paired-donor cohort study included 88 adult recipients of kidneys from 44 brain dead donors at collaborating centers in central India between January 2018 and December 2024. Group 1 (n = 44) received kidney retrieved first, before aortic clamping; group 2 (n = 44) received kidney retrieved last, after procurement of thoracic and remaining abdominal organs. Primary outcomes analyzed were cold ischemia time, delayed graft function, retrieval injury, and posttransplant hemodialysis. Secondary outcomes were first-hour urine output, day 8 serum creatinine, complications, graft loss, and mortality. We used multivariable logistic regression analyses to identify predictors of graft dysfunction. Results: Cold ischemia time was shorter in group 1 than in group 2 (78.4 +/- 48.37 vs 299.4 +/- 108.65 min; P < .001). Group 1 recipients had higher first-hour urine output (374.2 +/- 208.62 vs 186.1 +/- 124.92 mL; P < .001), lower day 8 serum creatinine (1.3 +/- 0.8 vs 3.1 +/- 2.83 mg/dL; P < .001), lesser delayed graft function requiring hemodialysis (9.1% vs 36.4%; P = .002), and fewer retrieval injuries and posttransplant complications (6.8% vs 38.6%; P < .001). Comparable advantages were observed among recipients of kidneys from expanded criteria donors. Retrieval of the kidney last independently predicted delayed graft function (adjusted odds ratio 3.92; 95% CI, 1.41-10.87; P = .008). Conclusions: Kidney-first retrieval markedly shortened cold ischemia time and improved early graft function and retrieval safety without compromising procurement of other organs and proved to be a pragmatic ischemia-minimization strategy.
