{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T16:33:12Z","timestamp":1793118792430,"version":"4.5.0"},"reference-count":46,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"6","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["JASN"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:list list-type=\"bullet\">\n                        <jats:list-item>\n                          <jats:p>Terminal renal resistance added prognostic value to kidney donor profile index (KDPI), especially in KDPI &gt;0.85 kidneys. Its effect was modest in KDPI \u22640.85 kidneys.<\/jats:p>\n                        <\/jats:list-item>\n                        <jats:list-item>\n                          <jats:p>Terminal renal resistance was found to be useful in guiding the acceptance of KDPI &gt;0.85 kidneys on the basis of estimated post-transplant survival.<\/jats:p>\n                        <\/jats:list-item>\n                        <jats:list-item>\n                          <jats:p>Terminal renal resistance \u22650.3 triggered kidney nonuse regardless of KDPI, but KDPI \u22640.85 kidneys should not be declined on the basis of resistance alone.<\/jats:p>\n                        <\/jats:list-item>\n                      <\/jats:list>\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Elevated terminal renal resistance on hypothermic machine perfusion is widely regarded as a marker of kidney quality and a trigger for kidney nonuse for transplantation, yet large-scale evidence is limited on whether terminal renal resistance adds prognostic value beyond kidney donor profile index (KDPI).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Adult kidney-only transplants performed using hypothermic machine perfusion (\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      =36,490) in the Organ Procurement and Transplantation Network database between March 31, 2015, and December 31, 2023, were included. Terminal renal resistance was categorized as &lt;0.2, 0.2\u20130.3, 0.3\u20130.4, and \u22650.4 mm Hg\/ml per minute. The primary outcome was 5-year graft survival. The association of terminal renal resistance with survival was analyzed to estimate the cutoff renal resistance for accepting high-KDPI (&gt;0.85) kidneys. Utilization analyses were performed in a separate donor cohort of 15,524 kidneys recovered using hypothermic machine perfusion from eight organ procurement organizations.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Higher renal resistance was independently associated with worse 5-year graft survival (hazard ratio for graft loss=1.49 [\u22650.4] versus &lt;0.2;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.001). The effect was modest in KDPI &lt;0.35 kidneys and was strongest in KDPI &gt;0.85 grafts. Renal resistance thresholds that were associated with better survival of using KDPI &gt;0.85 kidneys differed on the basis of candidate estimated post-transplant survival (EPTS; renal resistance &lt;0.2 for EPTS &lt;0.35, &lt;0.3 for EPTS 0.35\u20130.85, and &lt;0.4 for EPTS &gt;0.85). Utilization dropped sharply beyond a terminal renal resistance of 0.3 across all KDPI strata, disproportionate to the actual graft risk. Utilization of KDPI \u22640.85 grafts with renal resistance \u22650.30 could have yielded an estimated 357 (95% confidence interval, 304 to 377) additional transplants per year.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Terminal renal resistance was associated with long-term graft and patient survival, but this effect was clinically meaningful only in high-KDPI kidneys.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1681\/asn.0000000986","type":"journal-article","created":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T17:00:58Z","timestamp":1765386058000},"page":"1273-1283","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Renal Resistance on Hypothermic Machine Perfusion and Acceptance of Deceased Donor Kidney Allografts"],"prefix":"10.1681","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8216-0371","authenticated-orcid":false,"given":"Toshihiro","family":"Nakayama","sequence":"first","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical Center, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0705-3076","authenticated-orcid":false,"given":"Antony","family":"Attia","sequence":"additional","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical Center, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4243-3325","authenticated-orcid":false,"given":"Daniel J.","family":"Ahn","sequence":"additional","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical Center, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0614-5425","authenticated-orcid":false,"given":"Michael","family":"McCabe","sequence":"additional","affiliation":[{"name":"Transplant Institute, University of Rochester Medical Center, Rochester, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7187-0124","authenticated-orcid":false,"given":"Yutaka","family":"Endo","sequence":"additional","affiliation":[{"name":"Transplant Institute, University of Rochester Medical Center, Rochester, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Randeep S.","family":"Kashyap","sequence":"additional","affiliation":[{"name":"Transplant Institute, University of Rochester Medical Center, Rochester, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4526-6353","authenticated-orcid":false,"given":"Thomas A.","family":"Pham","sequence":"additional","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical Center, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7185-4383","authenticated-orcid":false,"given":"Marc L.","family":"Melcher","sequence":"additional","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical Center, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2514-5778","authenticated-orcid":false,"given":"Kazunari","family":"Sasaki","sequence":"additional","affiliation":[{"name":"Division of Abdominal Transplantation, Stanford Transplant Outcomes Research Center (STORC), Stanford University Medical Center, Stanford, California"},{"name":"Division of Abdominal Transplantation, Department of Surgery, Stanford University Medical 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