(ECD) and donation after cardiac death (DCD). Whether
long-term outcomes in the next decade will be negatively
influenced by the increased rate of DGF remains to be
determined.
DGF is a major obstacle for allograft survival as it can
be compounded by acute rejection and chronic allograft
nephropathy (CAN). Patients with both DGF and acute rejection
had a 5-year survival rate of 34% in US transplant
patients between 1985 and 1992 (13). A meta-analysis of
34 studies from 1988 through 2007 concluded that patients
with DGF had a 49% pooled incidence of acute rejection
compared to 35% incidence in non-DGF patients (12). Initial
associations have also been made at single centers
that identify DGF as one of the strongest risk factors for
CAN (RR 6.1) with greater risk than pretransplant diabetes
(RR 5.8) or pretransplant hypertension (RR = 3.1) (15). The
complex relationship between DGF and allograft durability
is still poorly understood due to the time lapse between
inciting event and outcome.
In this review we explore the risk factors for DGF proceeding
from the identification of a donor through the postoperative
period and beyond. We describe the substantive
mechanisms of ischemic and immunologic kidney injury
that have direct reference to transplant patients. Finally,
DGF prevention strategies are reviewed with emphasis on
therapeutic targets that relieve the ischemic condition and
diminish immunologic responses.