Pediatric deceased donor kidney transplant outcomes under the Kidney Allocation System

Abstract

The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post‐pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre‐KAS pDDKT (age <18 years) recipients (December 4, 2012–December 3, 2014) with the outcomes of 934 post‐KAS pDDKT recipients (December 4, 2014–December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post‐KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post‐KAS recipients had less graft loss than pre‐KAS recipients (hazard ratio [HR]: 0.350.540.83, P = .005) but no statistically significant differences in mortality (HR: 0.290.721.83, P = .5), DGF (odds ratio: 0.931.321.93, P = .2), and LOS (LOS ratio: 0.961.061.19, P = .4). After adjusting for donor–recipient characteristics, there were no statistically significant post‐KAS differences in mortality (adjusted HR: 0.371.042.92, P = .9), DGF (adjusted odds ratio: 0.941.412.13, P = .1), or LOS (adjusted LOS ratio: 0.931.041.16, P = .5). However, post‐KAS pDDKT recipients still had less graft loss (adjusted HR: 0.380.590.91, P = .02). KAS has had a mixed effect on short‐term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow‐up.

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

“…These issues are of particular importance for paediatric recipients who, as a result of excellent long‐term patient survival, require both extended primary graft survival and likely subsequent transplantation. A recent study by Ruck et al 28 in the United States showed that children with 3–6 HLA mismatches had a 43% increased risk of graft failure compared to those with 0–2 mismatches. Despite the introduction of progressive paediatric bonuses in Australia, there has been a gradual increase in mean HLA mismatches for paediatric recipients of deceased donor kidney transplants over the past three decades.…”

Changes in offer and acceptance patterns for pediatric kidney transplant candidates under the new Kidney Allocation System

“…While KAS has led to increased transplant rates for the highly sensitized, racial minorities, and certain blood types in the adult population, 9,[14][15][16] reports of the impact of KAS on the pediatric population have been mixed. [4][5][6]10 Notably, concern over decreased DDKT rates However, kidneys from donors 18-34 years old with KDPI < 35% were 23% less likely to be accepted post-KAS, even after adjusting for donor and recipient characteristics. This might be a consequence of increased selectivity of these high-quality kidneys, since these kidneys were actually 20% more likely to be offered to post-KAS pediatric candidates.…”

“…While KAS has led to increased transplant rates for the highly sensitized, racial minorities, and certain blood types in the adult population, reports of the impact of KAS on the pediatric population have been mixed . Notably, concern over decreased DDKT rates for certain pediatric candidates (particularly for candidates ≤6 years old) has led some to suggest that this is the direct result of KAS—that the policy is at fault—and that modifications to KAS should be considered .…”

“…We stratified by donor age (categorized as <18, 18‐34, and 35+ years) and KDPI (<35% and ≥35%) to reflect differing allocation prioritization pre‐ vs post‐KAS. To determine whether the offer rate per person‐year changed post‐KAS and to account for overdispersion of offer counts, we used negative binomial regression with offer rate as the dependent variable and actively waitlisted time post‐KAS as the primary exposure . We adjusted for candidate age, sex, race, primary diagnosis, time on dialysis, preemptive listing, and calculated panel‐reactive antibody (cPRA, modeled as 0%, 1%‐79%, and 80%+), and stratified by donor age (<18, 18‐34, 35+ years old) and KDPI (<35% vs ≥35%).…”

Utilisation of kidneys from deceased donors at increased risk of infectious disease transmission: a step in the right direction

“…The availability of NAT testing, the relatively high prevalence of IVDU and recent concerns about the access of children with ESKD to deceased donor kidneys in the USA [12] combine to make the use of IRD donors a more feasible option to patients, families and clinicians. Declining a kidney from an IRD donor prolongs median waiting time by 9.6 months (11.2 months among those under 6 years of age and 8.8 months among those on dialysis) [13].…”