Paediatric deceased donor kidney transplant in Australia: A 30‐year review—What have paediatric bonuses achieved and where to from here?

Abstract

Background In this 30‐year national review, we describe trends in DD transplantation for paediatric recipients, assess the impact of paediatric allocation bonuses and identify outstanding areas of need for this population. Methods A retrospective review of all DD kidney only transplants to paediatric recipients (<18 years old) in Australia between 1989 and 2018 was conducted using deidentified extracts from the ANZDATA. Results Of the 1011 kidney only transplants performed in paediatric recipients during the study period, 426 (42%) were from deceased donors. Paediatric candidates on the DD waiting list had consistently higher rates of transplantation and shorter time from dialysis initiation to transplantation compared with adult candidates (median 372 vs 832 days in 2018, for example). Donor characteristics remained more favourable for paediatric recipients, despite a decline in the overall quality of the donor pool. The mean number of HLA antigen mismatches for paediatric recipients of DD transplants increased each decade (2.86 [1989–1998], 3.85 [1999–2008], 4.01 [2009–2018]). Both patient and graft survival have improved for paediatric DD transplant recipients in the most recent era (5‐year graft and patient survival 85% vs 65% and 99% vs 94%, respectively, for 2009–2018 vs 1999–2008). Conclusions The current DD kidney allocation system in Australia provides rapid access to high‐quality organs for paediatric recipients, and early graft loss has decreased significantly in recent years; however, additional targeted interventions to address HLA matching may improve long‐term outcomes in this population.

Epidemiology and Outcomes of Children with Kidney Failure Receiving Kidney Replacement Therapy in Australia and New Zealand

“…Better early transplant outcomes and a reduction in risk of early graft loss have improved graft survival in the last decade. 18 , 19 The use of a tacrolimus/mycophenolate/prednisone regimen in the last decade, which was changed from a regimen of cyclosporine/mycophenolate/prednisone in the earlier decade, might have contributed to this early allograft loss risk reduction. 41 …”

“… 5 , 12 , 13 , 14 , 15 , 16 , 17 Since the 1980s, improved patient care and KRT policies have resulted in the acceptance of more challenging patients into pediatric KRT programs, including very young patients, and prioritization of pediatric patients with kidney failure as KT recipients. 1 , 16 , 18 , 19 , 20 Furthermore, PD has become the primary choice for dialysis for children and adolescents because of its better preservation of residual kidney function, tolerability, and cost-effectiveness. 10 , 16 , 21 , 22 , 23 , 24 , 25 …”

Cognitive and academic outcomes in children with chronic kidney disease

“…The high inter-cluster correlation scores (0.8–0.9) indicate that individual participant scores were generally stable over time, suggesting we could potentially lengthen the duration between assessments rather than obtaining more frequent measures of cognition and academic achievement. Paediatric priority access to kidney transplantation commenced in Australia in 2011 with a mean waiting time on dialysis of 1.25 years and consequently our prevalent dialysis population was reduced [ 29 ]. For this reason, our recruitment of patients on dialysis was limited and restricted our ability to separately quantify the effect of dialysis on cognition and academic outcomes compared to post-kidney transplantation.…”

Major technological advances will enhance Australian donor‐recipient matching and improve transplant outcomes

“…Lower HLA-EMMA scores are similarly associated with improved outcomes in transplantation. 8 Although not yet routinely available for all transplant matching, some Australian centres, in conjunction with their local Tissue Typing laboratories, do characterise eplets to reduce de novo DSA development, 9 improve long-term graft survival and increase access to subsequent transplants. Similarly, other centres are using careful eplet evaluation to increase donor offers for sensitised patients.…”