What does this research mean for the field?

Extended cold ischemia time (CIT) is associated with inferior long-term graft survival in kidney transplants, with a 10% increase in overall graft loss for CIT of 32-36 hours compared to 16-20 hours. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

What question did this study set out to answer?

To evaluate how increased cold ischemia time affects kidney graft survival and to assess associated allocation practices.

March 14, 2026Kidney International Reports0 citationsOpen Access

Impact of Cold Ischemia Time on Allograft Survival and Policy

SPSai Rithin PunjalaThe Ohio State University Wexner Medical Center ALApril LoganThe Ohio State University ALAshley LimkemannThe Ohio State University Wexner Medical Center

Key Points

To evaluate how increased cold ischemia time affects kidney graft survival and to assess associated allocation practices.
Analyzed United Network for Organ Sharing (UNOS) data from 2007-2023
Examined cold ischemia time during pre-KAS, KAS, and KAS250 eras
Assessed outcomes of kidney transplants under different allocation practices
Median cold ischemia time increased from 16 to 19.6 hours
10% increased graft loss for cold ischemia times of 32-36 hours compared to 16-20 hours
Every additional hour of cold ischemia time incrementally raised graft failure risk
Increased cold ischemia time for AOOS/EP kidneys in the KAS250 era
Changes in allocation affecting various kidney donor profile index groups

Abstract

Introduction: Changes in national allocation policy and regulatory practices have led to increases in cold ischemic time (CIT) and out-of-sequence allocation (AOOS) / expedited placement (EP) of deceased donor kidney transplants in the United States.The aims of this study were to gauge the clinical relevance of the increased CIT that accompanied KAS250, and to measure CIT for AOOS/EP kidneys.Methods: United Network for Organ Sharing (UNOS) data from 2007-2023 were analyzed across pre-KAS, KAS (kidney allocation system) and KAS250 eras.The impact of CIT on kidney graft survival and the CIT of kidneys undergoing AOOS/EP during these eras was assessed.Results: Median CIT increased from 16 hours to 19.6 hours, and the incidence of AOOS/EP increased from 0.5% to 13%.Transplants with CIT of 32-36 hours, had a 10% increase in overall graft loss compared to CIT of 16-20 hours (p=0.0002).For KDPI (kidney donor profile index) 20-34% and 35-85% groups, every additional hour of CIT increased the risk of graft failure by 0.5% (p=0.0019) and 0.4% (p85% declined from 9% to 7%, whereas AOOS/EP kidneys with KDPI <20% increased from 13% to 15% (p=0.0306).Conclusion: Current allocation practices do not prioritize CIT.Extended CIT is associated with inferior longterm graft survival.AOOS/EP is designed to prevent discards but does not currently target high KDPI kidneys.Our data provides a framework to assess the relative importance of CIT in allocation policy.

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