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Abstract: Since 1991, more than 50% of pediatric transplant recipients have received a living donor (LD) kidney, and ≈ 85% of these allografts were one‐haploidentical parental kidneys. Short‐term (1 yr) and long‐term (5 yr) graft survival of LD kidneys are 10% and 15% better, respectively, than that of cadaver donor (CD) kidneys. Because of these results, children are frequently not placed on a cadaver waiting list until the possibility of a LD is excluded – a process that may take up to 1 yr. The hypothesis for this study was that the graft outcome of a six‐antigen‐matched CD kidney is superior to that of a one‐haploidentical LD kidney, and that children are at a disadvantage by not being placed on a CD list whilst waiting for a LD. The database of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) for 11 yrs (1987–98), was reviewed to identify children who were recipients of a six‐antigen‐matched CD kidney (primary and repeat transplants), and those who were recipients of a one‐haploidentical LD kidney (primary and repeat transplants). Using standard statistical methods, the morbidity, rejection episodes, post‐transplant hospitalizations, renal function, long‐ and short‐term graft survival, and half‐life of primary recipients were compared in the two groups. Unlike adult patients, only 2.7% (87/3313) of CD recipients in the pediatric age range received a six‐antigen‐matched kidney, and the annual accrual rate over 11 yrs was never higher than 4%. Comparison of 57 primary six‐antigen‐CD kidneys (PCD) with 2472 primary LD (PLD) kidneys revealed that morbidity, rejection rates, and ratios were identical in the two groups. Renal function and subsequent hospitalizations were also identical in the two groups. Five‐year graft survival of the PCD group was 90% compared with 80% for the PLD group, and the half‐life of the PCD group was 25 ± 12.9 yrs compared with 19.6 ± 1.3 yrs. Our data suggest that the six‐antigen‐matched CD kidney may have less graft loss as a result of chronic rejection and would therefore confer a better long‐term outcome. Based on these findings we recommend that all children, whilst waiting for a LD work‐up, be listed with the United Network for Organ Sharing (UNOS) registry for a CD kidney. [ABSTRACT FROM AUTHOR]

Abstract: We define delayed graft function (DGF) as the need for dialysis during the first post‐transplant week. We analyzed 5272 transplants, of which 2486 were of living donor (LD) and 2786 were of cadaver donor (CD) origin. Twelve per cent (620/5272) of all patients developed DGF. Donor specific rates were 5.6% for LD and 19.1% for CD patients. Factors predictive of DGF in CD patients were: African‐American race (25%), prolonged cold ischemia (24%), absence of T‐cell induction antibody therapy and absence of HLA‐DR matching. The relative risk (RR) for graft failure due to DGF was 6.02 (p < 0.001) in LD patients and 2.58 (p < 0.001) for CD recipients. Two‐year graft survival (GS) in LD patients without DGF was 89.6%, compared to 41.6% for those with DGF (p < 0.001); in CD patients it was 80.2% and 49.5%, respectively (p < 0.001). Censoring for primary non‐function, GS for LD patients with a functioning graft at 30 d post‐transplant and no DGF was 91.5%, compared to 70.1% for those with DGF (p < 0.001); GS for CD patients was 83.8% and 68.7%, respectively (p < 0.001). However, when patients whose grafts had failed during the first year were censored no differences in GS were noted between patients with and without DGF for either LD or CD recipients. To determine whether DGF acts as an independent risk factor for graft failure, patients were segregated into four groups: rejection with DGF; rejection without DGF; DGF without rejection; and no DGF, no rejection. When these groups were compared DGF emerged as an independent risk factor for graft failure. This large study reviewing pediatric renal transplantation over 10 yr clearly delineates the role of DGF as a major risk factor for graft failure. [ABSTRACT FROM AUTHOR]