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In late February 2021, the first cases of vaccine-induced thrombosis and thrombocytopenia (VITT) were observed in patients after immunization with the ChAdOx1 nCoV-19 adenoviral vector vaccine (Oxford, AstraZeneca) against SARS-CoV-2.1 This prothrombotic response is presumed to be mediated by anti-platelet factor 4 (PF4) antibodies that activate platelets and induce activation and extracellular traps formation of neutrophils.2 These antibodies can also be seen in autoimmune heparin-induced thrombocytopenia, but all the described cases had no previous exposure to heparin.

Background Acute-on-chronic kidney disease (ACKD) is poorly understood and often overlooked. We studied its incidence, circumstances, determinants and outcomes in patients with CKD. Methods We used the Kidney Disease: Improving Global Outcomes criteria to identify all-stage acute kidney injury (AKI) events in 3033 nephrology outpatients with CKD Stages 3–5 participating in the CKD-Renal Epidemiology and Information Network cohort study (2013–20), and cause-specific Cox models to estimate hazard ratios [HRs; 95% confidence intervals (CIs)] of AKI-associated risk factors. Results At baseline, 22% of the patients [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] had a history of AKI. Over a 3-year follow-up, 443 had at least one AKI event: 27% were Stage 2 or 3 and 11% required dialysis; 74% involved hospitalization including 47% acquired as hospital inpatients; and a third were not reported in hospital discharge reports. Incidence rates were 10.1 and 4.8/100 person-years in patients with and without an AKI history, respectively. In 2375 patients without this history, male sex, diabetes, cardiovascular disease, cirrhosis, several drugs, low eGFR and serum albumin levels were significantly associated with a higher risk of AKI, as were low birth weight ( Conclusions The study highlights the high rate of hospital-acquired AKI events in patients with CKD, and their underreporting at hospital discharge. It also reveals low birth weight and anaemia as possible new risk factors in CKD patients.

In recent decades, the allocation policies of many countries have moved from center-based to patient-based approaches. The new French kidney allocation system (KAS) of donations after brain death for adult recipients, implemented in 2015, was principally designed to introduce a unified allocation score (UAS) to be applied locally for one kidney and nationally for the other and to replace regional borders by a new geographical model. The new KAS balances dialysis duration and waiting time to compensate for listing delays and provides more effective longevity matching between donors and recipients with better HLA and age matching. We report these changes, with their rationale and main results. Results show improved HLA matching for young recipients and more rapid access to transplant for older recipients. Young recipients also had better access to transplantation. Transplant access decreased for recipients aged 60-69 and required tuning of KAS parameters. In conclusion, our results strongly indicate that national or adequately broad geographic allocation areas, combined with multiplicative interactions between allocation criteria, permit multivariate optimization of organ allocation and thus improve national kidney sharing and balance HLA matching and age matching, at the price of longer cold ischemic times and more logistical constraints than with local allocation.

Late stages of CKD are characterized by significant symptom burden. This study aimed to identify subgroups within the 5-year trajectories of symptom evolution in patients with CKD and to describe associated patient characteristics and outcomes.Among 2787 participants (66% men) with eGFR60 ml/min per 1.73 mPatient mean age (±SD) at baseline was 67±13 years, and mean eGFR was 33±13 ml/min per 1.73 mThis study highlights a significant worsening of symptoms in about one third of the participants, whereas the majority reported low symptom severity throughout the study.

BACKGROUND AND AIMS Men are at higher risk of cardiovascular disease (CVD) than women in the general population, and chronic kidney disease (CKD) is a well-established cardiovascular (CV) risk factor [1–4]. However, the incidence of cause-specific CV events in men and women with CKD is poorly documented. METHOD All hospitalization and death reports for CV events of the 3033 patients (1983 men and 1050 women) with non-dialysis CKD (stage 3–5) included in the French CKD-REIN Cohort were reviewed and classified by cause using criteria from the Cardiovascular and Stroke Endpoint Definitions for Clinical Trials [5]. Cause-specific Cox proportional hazard models were used to estimate hazard ratios for death and each fatal or nonfatal CV event according to gender. RESULTS At baseline, in men (mean age: 68 years; mean eGFR 33 mL/min/1.73 m²), the prevalence of atheromatous CVD was 30% for coronary artery disease, 14% for cerebrovascular disease and 17% for lower limb artery disease, and that of non-atheromatous CVD was 14% for heart failure and 13% for atrial fibrillation. In women (65 years old, 32 mL/min/1.73 m²), these prevalences were 15%, 7%, 9%, 11% and 9%, respectively. During a median follow-up of 5 (IQR: 3–5) years, 98 men and 43 women died from CVD {i.e. 1.3 [95% confidence interval (95% CI): 1.0–1.5] versus 1.0 (0.7–1.3)/100 person-years}, including 53% versus 46% from heart failure, 31% versus 19% from sudden death, and 16% versus 35% from other cardiovascular causes, respectively. Crude incidence rates of death or hospitalization for coronary artery disease and lower limb artery disease were higher in men than in women, slightly higher for CV death, cerebrovascular disease and atrial fibrillation, but similar for both genders for heart failure (Fig. 1). History of CVD was strongly associated with subsequent CV events of any type. In multivariable analyses, gender was no longer associated with any cause-specific CV event, whereas a lower eGFR was significantly associated with an increased risk of coronary artery disease and heart failure, but not with other CV events (Table 1). CONCLUSION In patients with moderate or advanced CKD, the burden of atheromatous CVD is higher in men than in women and explained by their higher prevalence of cardiovascular risk factors, but that for heart failure and atrial fibrillation appears to be similar for both genders.

BACKGROUND AND AIMS Chronic kidney disease (CKD) is a risk factor for cognitive impairment. In the general population, many risk factors have been reported in association with incident major neurocognitive disorders. The link between CKD and cognitive dysfunction is not completely understood; it may involve different mechanisms such as vascular dysfunction or uremic toxin toxicity. We aimed to assess the influence of cardiovascular risk factors, cardiovascular disease and depression on the association between kidney function and cognitive function in patients with CKD. METHOD We analyzed baseline data from 3033 patients with CKD stage 3–5 included in the Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort between 2013 and 2016. Cognitive function was assessed with the Mini Mental State Examination (MMSE), and the glomerular filtration rate was estimated with the CKD EPI formula. We applied unadjusted and adjusted linear and logistic regression models, with the MMSE score as a continuous or categorical variable (at a cut-off point at 24/30). RESULTS The mean patient age was 66.8, the mean estimated glomerular filtration rate (eGFR) was 33 mL/min/1.73 m2 and 393 patients (13.0%) had a MMSE score The eGFR was positively associated with the MMSE score before and after adjustment for age, sex, education level, cardiovascular risk factors, cardiovascular disease and depression, giving point increases in the MMSE score of 0.24 (0.15–0.33; P < .001) and 0.14 (0.04–0.23; P = .006) for a 10 mL/min/1.73 m2 increment in the eGFR, respectively. Other risk factors significantly associated with a lower MMSE score in multivariate analysis were age, female sex, lower educational level, diabetes, obesity, cerebrovascular disease, atrial fibrillation and CES-D-10 score. The eGFR was associated with a low MMSE score (defined as MMSE score CONCLUSION In a cohort of well-phenotyped patients with CKD, lower eGFR is associated with worse cognitive function, independent of age, sex, educational level, cardiovascular injury and depression.

BACKGROUND AND AIMS The objective of this observational study was to describe the `DAPA-CKD-like’ population and to assess the burden of illness (comorbidities, cardiovascular (CV) and renal events) and prognosis in patients with CKD in France, compared with those randomized in the DAPA-CKD RCT [1]. METHOD The CKD-REIN cohort study enrolled 3033 patients with moderate or advanced CKD from 40 nationally representative nephrology clinics in France [median age of 68 (IQR: 60–76), min-max: 19–94, 65% men, CKD stage 3 (60%) or 4 (40%)]. Inclusions started in July 2013 and ended in July 2016. The analysis describes baseline characteristics of patients with DAPA-CKD inclusion criteria (75 ≥ eGFR ≥ 25 mL/min/1.73 m2 and 5000 ≥ UACR ≥ 200 mg/g) and CV and renal outcomes >3-year follow-up. RESULTS Among the 3033 adult patients included in CKD-REIN cohort, 503 met the inclusion and exclusion criteria of the DAPA-CKD RCT. The characteristics of these 503 French `DAPA-CKD-like’ patients and those of the DAPA-CKD RCT were similar in terms of age (63.9 ± 13.6 versus 61.8 ± 12.1), gender (74% men versus 67%), eGFR (36.5 ± 9.1 mL/min/1.73 m2 versus 43.1 ± 12.4 mL/min/1.73 m2) and SBP (145 ± 21 mmHg versus 137 ± 17 mmHg). The CV and renal event rates/100 patient-year (PY) were similar between the two populations, both for the main composite outcome (eGFR decline ≥50% or end-stage kidney disease (defined as eGFR CONCLUSION In conclusion, the DAPA-CKD RCT patient profile appears to be similar to a real-life French CKD patient profile based on the French CKD-REIN cohort meeting the inclusion and exclusion criteria of the DAPA-CKD RCT.

BACKGROUND AND AIMS Elevated serum urea levels are common in moderate-to-advanced CKD. Several studies have shown that urea is a direct and indirect uremic toxin, especially with regard to cardiovascular disease. We sought to determine whether serum urea levels are associated with adverse cardiovascular events and death before kidney replacement therapy (KRT) in patients with CKD. METHOD CKD-REIN is a prospective cohort of CKD nephrology outpatients not receiving maintenance dialysis. The 2507 patients included in the analysis were divided into three groups according to the baseline serum urea level (T1 RESULTS Of the 2507 included patients {median [first quartile–third quartile (Q1–Q3)] age: 69 (61–77); mean (standard deviation) eGFR 33.5(11.6) mL/min/1.73 m²}, 54% had a history of cardiovascular disease. Over a median follow-up of 3.0 years [Q1–Q3, 2.2–3.1], 451 experienced their first atheromatous or nonatheromatous cardiovascular event (fatal or nonfatal), leading to an incidence rate (IR) [95% confidence interval (95% CI)] of 7.1 (6.4–7.7)/100 person-years (PYs) (Fig. 1). Over a median follow-up period of 4.8 (3.3–5.1) years, 407 patients died before KRT, leading to an IR of 4.0 (3.6–4.3)/100 PYs. After multiple adjustments for cardiovascular risk factors (including eGFR), patients in T3 had a higher risk of atheromatous and nonatheromatous cardiovascular events than patients in T1 [HR (95% CI), 2.08 (1.50–2.88), Fig. 1]. A nonsignificant trend towards a higher risk was also noted for patients in T2 [1.28 (0.96–1.71)]. The adjusted HRs for death before KRT were 1.30 (0.96–1.75] and 1.73 (1.22–2.45) for patients in T2 and those in T3, respectively. CONCLUSION Beyond CV risk factors including eGFR, this hypothesis-generating study suggests that serum urea level is a predictor of cardiovascular outcomes in patients with moderate to advanced CKD. Further research is needed to confirm current findings and explore mechanisms.

Background Elevated serum urea levels are common in moderate-to-advanced chronic kidney disease (CKD). Several studies have shown that urea is a direct and indirect uraemic toxin, especially with regard to cardiovascular disease. We sought to determine whether serum urea levels are associated with adverse cardiovascular events and death before renal replacement therapy (RRT) in patients with CKD. Methods CKD-REIN is a prospective cohort of CKD nephrology outpatients not receiving maintenance dialysis. The 2507 patients included in the analysis were divided into three groups according to the baseline serum urea level (T1 Findings Of the 2507 included patients {median [interquartile range (IQR)] age: 69 [61–77]; mean (standard deviation) estimated glomerular filtration rate (eGFR) 33.5 (11.6) mL/min/1.73 m²}, 54% had a history of cardiovascular disease. After multiple adjustments for CV risk factors (including eGFR), patients in T3 had a higher risk of atheromatous and non-atheromatous CV events than patient in T1 (n events = 451, HR [95% CI]: 1.93 [1.39; 2.69]). The adjusted HRs for death before RRT (n events = 407) were 1.31 [0.97; 1.76] and 1.73 [1.22; 2.45] for patients T2 and those in T3, respectively. Interpretation Our data suggested that urea is a predictor of CV outcomes beyond CV risk factors including eGFR.

Background Conservative care is increasingly considered an alternative to kidney replacement therapy for kidney failure management, mostly among the elderly. We investigated its status and the barriers to its implementation from patients’ and providers’ perspectives. Methods We analysed data from 1204 patients with advanced chronic kidney disease (CKD) [estimated glomerular filtration rate (eGFR) Results All participating facilities reported they were routinely able to offer conservative care, but only 37% had written protocols and only 5% had a person or team primarily responsible for it. Overall, 6% of patients were estimated to use conservative care. Among nephrologists, 82% reported they were fairly or extremely comfortable discussing conservative care, but only 28% usually or always offered this option for older (>75 years) patients approaching kidney failure. They used various terminology for this care, with conservative management and non-dialysis care mentioned most often. Among patients, 5% of those >75 years reported receiving information about this option and 2% preferring it. Conclusions Although reported by nephrologists to be widely available and easily discussed, conservative care is only occasionally offered to older patients, most of whom report they were not informed of this option. The lack of a person or team responsible for conservative care and unclear information appear to be key barriers to its implementation.

International audience; Objective: Conflicting findings and knowledge gaps exist regarding links between anemia, physical activity, health-related quality of life (HRQOL), chronic kidney disease (CKD) progression, and mortality in moderate-to-advanced CKD. Using the CKD Outcomes and Practice Patterns Study, we report associations of hemoglobin (Hgb) with HRQOL and physical activity, and associations of Hgb and physical activity with CKD progression and mortality in stage 3-5 nondialysis (ND)-CKD patients. Design and Methods: Prospectively collected data were analyzed from 2,121 ND-CKD stage 3-5 patients, aged ≥18 years, at 43 nephrologist-run US and Brazil CKD Outcomes and Practice Patterns Study–participating clinics. Cross-sectional associations were assessed of Hgb levels with HRQOL and physical activity levels (from validated Kidney Disease Quality of Life Instrument and Rapid Assessment of Physical Activity surveys). CKD progression (first of ≥40% estimated glomerular filtration rate [eGFR] decline, eGFR12 g/dL. Odds of being highly physically active were substantially greater at Hgb>10.5 g/dL. Lower Hgb was strongly associated with greater CKD progression and mortality, even after extensive adjustment. Physical inactivity was strongly associated with greater mortality and weakly associated with CKD progression. Possible residual confounding is a limitation. Conclusion: This multicenter international study provides real-world observational evidence for greater HRQOL, physical activity, lower CKD progression, and greater survival in ND-CKD patients with Hgb levels >12 g/dL, exceeding current treatment guideline recommendations. These findings help inform future studies aimed at understanding the impact of new anemia therapies and physical activity regimens on improving particular dimensions of ND-CKD patient well-being and clinical outcomes.

Introduction In the general population, urinary sodium-to-potassium (uNa/K) ratio associates more strongly with high blood pressure (BP) than either urinary sodium or potassium alone. Whether this is also the case among patients with chronic kidney disease (CKD) is unknown. Methods We studied the associations of spot urine sodium-to-creatinine (uNa/Cr), potassium-to-creatinine (uK/Cr), and uNa/K ratios with a single office BP reading in 1660 patients with moderate to severe CKD at inclusion in the CKD-REIN cohort. Results Patients' median age was 68 (interquartile range [IQR], 59–76) years; most were men (65%), had moderate CKD (57%), and albuminuria (72%). Mean systolic and diastolic BP was 142/78 mm Hg. Spot uNa/Cr and uNa/K ratios were positively associated with systolic, mean arterial, and pulse pressures. The mean adjusted difference in systolic BP between the highest and the lowest quartile (Q4 vs. Q1) was 4.24 (95% confidence interval [CI], 1.53–6.96) mm Hg for uNa/Cr and 4.79 (95% CI, 2.18–7.39) mm Hg for uNa/K. Quartiles of spot uK/Cr were not associated with any BP index. The higher the quartile of uNa/K, the higher the prevalence ratio of uncontrolled (Q4 vs. Q1, 1.43; 95% CI, 1.19–1.72) or apparently treatment-resistant hypertension (Q4 vs. Q1, 1.35; 95% CI, 1.14–1.60). Findings were consistent in a subset of 803 individuals with 2 BP readings. Conclusion In patients with CKD, higher urinary sodium excretion is associated with higher BP, but unlike in general population, lower potassium excretion is not. Urinary Na/K does not add significant value in assessing high BP risk, except perhaps for hypertension control assessment., Graphical abstract

International audience; RATIONALE & OBJECTIVE: Health-related quality of life (HRQoL) is a major outcome measure increasingly used in patients with chronic kidney disease (CKD). We evaluated the association between different stages of CKD and the physical and mental health domains of HRQoL.STUDY DESIGN: Cross-sectional study.SETTING & PARTICIPANTS: 2,693 outpatients with moderate (stage 3, estimated glomerular filtration rate [eGFR], 30-60mL/min/1.73m2) or advanced (stages 4-5, estimated glomerular filtration rate40% of those with advanced CKD or receiving dialysis, 12% with a functioning transplant, and 3% of the general population sample. HRQoL physical scores (adjusted for age, sex, education, obesity, and diabetes) were significantly lower in patients in all CKD subgroups than in the general population. For patients receiving dialysis, the magnitude of the difference in physical score versus the general population exceeded 4.5 points, the minimal clinically important difference for this score in this study; for both kidney transplant recipients and patients with advanced CKD, the magnitude of the difference was close to this threshold. For mental score, only dialysis patients had a score that differed from that of the general population by more than the minimal clinically important difference.LIMITATIONS: Cross-sectional study design for each subpopulation.CONCLUSIONS: This study highlights the degree to which perceived physical health is lower in the setting of CKD than in the general population, even in the absence of kidney failure, and calls for greater attention to CKD-related quality of life.

Resume L’acces a la greffe renale pour les patients insuffisants renaux chroniques terminaux est un enjeu majeur en France. L’inscription sur liste d’attente de greffe est une etape obligatoire pour pouvoir acceder a cette technique. La Haute Autorite de sante a mis a jour, en 2015, les contre-indications a l’acces a cette liste. Dans ce contexte, nous avons voulu realiser un etat des lieux des motifs de non-inscription sur la liste d’attente de greffe renale chez les patients dialyses depuis au moins un an, âges de moins de 80 ans, en France. Tous les patients inclus dans le registre d’epidemiologie et d’information en nephrologie (REIN), devant avoir leur point annuel de suivi du 1er aout au 30 novembre 2016 repondant aux criteres, ont ete inclus et un questionnaire dedie a ete rempli par leur centre de dialyse. Ainsi, 3172 patients ont ete analyses : 2302 (73 %) avaient une contre-indication medicale a la greffe, le plus souvent (33 %) vasculaire, 458 (14 %) refusaient d’etre inscrits, avec proportionnellement plus de femmes dans cette categorie et enfin, chez 412 patients (13 %), on ne retrouvait pas de motif renseigne dans notre questionnaire. Neanmoins, pour 65 % des patients de cette derniere categorie, un bilan en vue d’une inscription etait debute. Il y avait donc, dans notre cohorte, seulement 144 patients (4,5 %) sans explication a la non-inscription. Cette etude nationale est la premiere a donner a un etat des lieux des motifs de non-inscription sur liste de greffe renale en France. Sans surprise, la contre-indication medicale est le premier motif de non-inscription dans cette population de patients chroniques. Le fort taux de refus doit etre souligne et analyse plus precisement, notamment avec le ressenti du patient. Et enfin, tres peu de patients n’ont pas de motif renseigne ou de bilan en cours.

Background The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists. Methods The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that ‘initiated imminently or Results Over a 4-year (interquartile range 3.0–4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08–4.25] or with low health literacy [2.22 (95% CI 1.28–3.84)], heart failure [2.60 (95% CI 1.47–4.57)] or hyperpolypharmacy [taking >10 drugs; 2.14 (95% CI 1.17–3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19–1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70–0.94)] for each visit. Conclusions This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.

A new lung allocation system was introduced in France in September 2020. It aimed to reduce geographic disparities in lung allocation while maintaining proximity. In the previous two-tiered priority-based system, grafts not allocated through national high-urgency status were offered to transplant centres according to geographic criteria. Between 2013 and 2018, significant geographic disparities in transplant allocation were observed across transplant centres with a mean number of grafts offered per candidate ranging from 1.4 to 5.2. The new system redistricted the local allocation units according to supply/demand ratio, removed regional sharing and increased national sharing. The supply/demand ratio was defined as the ratio of lungs recovered within the local allocation unit to transplants performed in the centre. A driving time between the procurement and transplant centres of less than 2 h was retained for proximity. Using a brute-force algorithm, we designed new local allocation units that gave a supply/demand ratio of 0.5 for all the transplant centres. Under the new system, standard-deviation of graft offers per candidate decreased from 0.9 to 0.5 (p = 0.08) whereas the mean distance from procurement to transplant centre did not change. These preliminary results show that a supply/demand ratio-based allocation system can achieve equity while maintaining proximity.

Resume Introduction L’etat des lieux de la prise en charge de la maladie renale chronique avant le deploiement du forfait-parcours des patients est important a connaitre pour permettre d’en mesurer l’impact a terme. Patients et methodes Nous avons decrit la prise en charge en nephrologie sur 3 ans de 2835 patients ayant une maladie renale chronique moderee a severe, suivis dans la cohorte CKD-REIN entre 2013 et 2019, et son adequation au referentiel de la Haute Autorite de Sante en vigueur sur la periode. Resultats Le nombre moyen de consultations nephrologiques des patients (âge moyen 67 ans ; 65 % d’hommes ; 43 % de MRC stade 4 ou 5) augmentait de 1,1 a 2,7 par an, du stade 3A au stade 5 de la maladie renale chronique. Aux stades 3B, 4 et 5, respectivement 84, 63 et 33 % des patients avaient le nombre minimum de consultations de nephrologie recommande par la Haute Autorite de Sante. Au stade 4 ou 5 de la maladie renale chronique, seuls 34 et 40 % des patients, respectivement, avaient beneficie de consultation dietetique, et 33 et 54 % avaient recu des informations sur les options de traitement. Le delai moyen d’attente pour une premiere consultation de nephrologie etait plus long (60 vs 45 jours), et leur duree moyenne plus courte (30 vs 38 a 40 minutes) en CHU compare aux centres hospitaliers et aux etablissements prives. Conclusion L’ecart important constate entre les pratiques reelles et les recommandations temoigne des limites des ressources humaines et des organisations dans la prise en charge de la maladie renale chronique en nephrologie, pour lesquelles des avancees sont attendues avec le financement au forfait.

Despite improvements in organ preservation techniques and efforts to minimize the duration of cold ischemia, ischemia–reperfusion (IR) injury remains associated with poor graft function and long-term survival in kidney transplantation. We recently demonstrated a clinically significant day-time variation in myocardial tolerance to IR, transcriptionally orchestrated by the circadian clock. Patient and graft post-transplant survival were studied in a cohort of 10,291 patients first transplanted between 2006 and 2017 to test whether kidney graft tolerance to IR depends on the time-of-the-day of clamping/declamping, and thus impacts graft and patient survival. Post-transplant 1- and 3-year survival decreased with increasing ischemia duration. Time-of-the-day of clamping did not influence outcomes. However, night-time (vs. day-time) declamping was associated with a significantly worse post-transplant survival. After adjustment for other predictors, night-time (vs. day-time) declamping remained associated with a worse 1-year (HR= 1.26 (1.08–1.47), p = 0.0028 by Cox multivariable analysis) and 3-year (HR= 1.14 (1.02–1.27), p = 0.021) outcome. Interestingly, the deleterious impact of prolonged ischemia time (&gt, 15 h) was partially compensated by day-time (vs. night-time) declamping. Compared to night-time declamping, day-time declamping was associated with a better prognosis of kidney transplantation despite a longer duration of cold ischemia.