Cold ischemia time exceeding 12 hours is a risk factor for delayed graft function and increased mortality in kidney transplant recipients within the eurotransplant senior program.

With the age of those awaiting kidney transplantation (KTx) increasing, the Eurotransplant Senior Program (ESP) reduces median waiting time by > 1.5 years for patients aged ≥65 compared to standard allocation and doubles life expectancy compared with remaining on dialysis. However, older-donor organs are more vulnerable to prolonged cold ischemia time (CIT). To minimize CIT, both kidneys from one donor are regionally allocated, in our case, to a single transplant center. This study assesses the impact of CIT on delayed graft function (DGF) and long-term outcomes in consecutively transplanted ESP recipients from the same donor. We retrospectively analyzed 208 ESP KTx at Freiburg Transplant Center (1999-2019), focusing on 74 consecutively transplanted kidney pairs (recipients ranked "1" or "2"). DGF incidence was similar for rank 1 and rank 2 recipients. CIT >12 h significantly increased DGF risk versus CIT <8 h (adjusted OR 6.30; 95% CI 1.52-26.06; p = 0.011). Death-censored allograft survival was unaffected, but CIT >12 h tripled mortality risk (adjusted HR 3.19; 95% CI 1.44-7.49; p = 0.005). Consecutive transplantation does not disadvantage the second recipient if CIT remains <12 h. CIT >12 h independently predicts DGF and higher mortality, emphasizing the need to minimize ischemia time.