Outcomes and Risk Factors for Graft Loss: Lessons Learned from 1,056 Pediatric Kidney Transplants at the University of Minnesota

Background Advances in immunosuppression, surgical techniques, and management of infections in children receiving kidney transplants have affected outcomes. Study Design We analyzed a prospectively maintained database of pediatric kidney transplantations. Results From June 1963 through October 2016, we performed 1,056 pediatric kidney transplantations. Of these, 129 were in children less than 2 years old. The most common indications for transplant were congenital anomalies (dysplastic kidneys), obstructive uropathy, and congenital nephrotic syndrome. Living donors constituted 721 (68%) of all donors. The graft and patient survival rates remarkably improved for both deceased and living donor recipients (p = 0.001). Currently, graft survival rates for deceased donor recipients are 92% at 1 year, 76% at 5 years, and 57% at 10 years post-transplant; for living donor recipients, 96% at 1 year, 85% at 5 years, and 78% at 10 years. The graft half-life was 19 years in deceased donor recipients, compared with 25 years in living donor recipients (p ≤ 0.001). Acute rejection was the most common cause of graft loss in the first year post-transplant. The following risk factors were associated with an increased risk of graft loss: deceased donor grafts (p = 0.0001), retransplant (p = 0.02), ages 11 to 18 years (p = 0.001) and pre-transplant urologic issues (p = 0.04). Living donor grafts (p ≤ 0.0001) and pre-emptive transplants (p = 0.02) were associated with decreased risks of graft loss. Conclusions The success rates of pediatric kidney transplants have significantly improved. Pre-emptive kidney transplantation with a living donor graft continues to be superior and should be the choice in children with end-stage renal disease.