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Pediatric Kidney Transplant Outcomes After Kidney Donor Profile Index-Based Organ Prioritization
Syed Ali Husain1,2, Darren Stewart1, Babak J Orandi1,2
1Department of Surgery, NYU Langone Health, New York, New York, USA.
Pediatric Transplantation
|January 28, 2026
Summary
The Kidney Allocation System (KAS) prioritizes deceased donor kidneys for pediatric transplant candidates, showing a lower risk of graft failure compared to the previous donor age-based system. This change improves long-term pediatric kidney transplant outcomes.
Area of Science:
- Nephrology
- Transplant Surgery
- Public Health Policy
Background:
- The U.S. Kidney Allocation System (KAS), implemented in 2014, prioritizes deceased donor kidneys with a kidney donor profile index (KDPI) < 35% for pediatric candidates.
- Early data suggested potential increases in delayed graft function post-KAS compared to the pre-KAS era, which used donor age < 35 years for pediatric priority.
- The impact of this KAS allocation change on long-term pediatric kidney transplant outcomes requires further investigation.
Purpose of the Study:
- To evaluate the effect of the KAS kidney allocation policy on pediatric kidney transplant outcomes.
- To compare graft failure rates in pediatric recipients between the pre-KAS and KAS eras.
Main Methods:
- Utilized data from the Scientific Registry of Transplant Recipients (SRTR) for deceased donor kidney transplants in pediatric recipients.
- Defined two study eras: Pre-KAS (12/1/2009-11/30/2014) and KAS (12/1/2015-11/30/2020).
- Employed Cox proportional hazards models to assess the association between the study era and all-cause graft failure, adjusting for recipient characteristics.
Main Results:
- A total of 4502 pediatric kidney transplants were analyzed, with 2175 in the pre-KAS era and 2327 in the KAS era.
- KAS-era donors were older and had better kidney function indicators (lower serum creatinine) compared to pre-KAS donors.
- Transplantation during the KAS era was associated with a significantly lower hazard of graft failure (adjusted HR 0.79, p=0.001), consistent in sensitivity analyses.
Conclusions:
- Kidney donor profile index (KDPI)-based prioritization for pediatric kidney allocation under KAS is linked to a reduced risk of graft failure.
- This contrasts with the previous donor age-based prioritization strategy.
- Further refinement of donor risk scoring systems could potentially enhance graft survival rates in pediatric kidney transplantation.
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