Impact of the kidney allocation system on young pediatric recipients

Clin Transplant. 2018 Apr;32(4):e13223. doi: 10.1111/ctr.13223. Epub 2018 Mar 14.


The kidney allocation system (KAS) altered pediatric candidate prioritization. We determined KAS's impact on pediatric kidney recipients by examining delayed graft function (DGF) rates from 2010 to 2016. A propensity score-matched pediatric recipients pre- and post-KAS. A semiparametric decomposition analysis estimated the contributions of KAS-related changes in donor characteristics and dialysis time on DGF rate. The unadjusted odds of DGF were 69% higher post-KAS for young (<10 years at listing) recipients (N = 1153, P = .02) but were not significantly increased for older pediatric (10-17 years at listing) recipients (N = 2624, P = .48). Post-KAS, young recipients received significantly fewer pediatric (<18 years) donor kidneys (21% vs 32%, P < .01) and had longer median pretransplant dialysis time (603 vs 435 days, P < .01). After propensity score matching, post-KAS status increased the odds of DGF in young recipients 71% (OR 1.71, 95% CI 1.01-2.46). In decomposition analysis, 24% of the higher DGF rate post-KAS was attributable to donor characteristics and 19% to increased recipient dialysis time. In a confirmatory survival analysis, DGF was associated with a 2.2 times higher risk of graft failure (aHR2.28, 95% CI 1.46-3.54). In conclusion, KAS may lead to worse graft survival outcomes in children. Allocation changes should be considered.

Keywords: classification systems; delayed graft function; kidney (allograft) function/dysfunction; pediatric transplantation; waitlist management.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Child
  • Child, Preschool
  • Delayed Graft Function / mortality*
  • Female
  • Follow-Up Studies
  • Glomerular Filtration Rate
  • Graft Rejection / mortality*
  • Graft Survival
  • Humans
  • Kidney Failure, Chronic / surgery*
  • Kidney Function Tests
  • Kidney Transplantation / mortality*
  • Male
  • Postoperative Complications / mortality*
  • Prognosis
  • Resource Allocation / statistics & numerical data*
  • Risk Factors
  • Survival Rate
  • Tissue Donors
  • Tissue and Organ Procurement / methods*
  • Waiting Lists