The future of pediatric renal transplantation with machine perfusion technology at the frontier

Renal transplantation is the only curative treatment approach for children with end-stage kidney disease, ensuring the best possible growth, neurocognitive and social development. However, the field of pediatric kidney transplantation is highly heterogeneous with different indications, timing, graft types, institutional standards, and recipient anthropometrics. The availability of suitable grafts is limited, especially for small recipients. While hypothermic, normothermic machine perfusion (HMP/NMP) and normothermic regional perfusion (NRP) approaches are rapidly dominating the field of adult kidney transplantation, their role in the pediatric setting remains largely unexplored. This review discusses the current state-of-the-art of MP of the kidney focusing on the lessons learned from adult studies. Based on the synthesis of the available evidence, we give a futuristic overview on how MP might enter the pediatric arena in the upcoming years and change the way we treat children undergoing renal transplantation. Clinical studies in pediatric kidney transplantation using MP are awaited. Due to limited caseload in most centers and vulnerable patient population, strong international collaborations are needed to investigate the value and limitations of perfusion technology in the pediatric cohort, in which improved outcomes are not just associated with quantitative results, such as improved survival data, but might indeed define the entire future and psychosocial chances of the affected children in their life.