Repeat transplantation practices among pediatric kidney transplant recipients

Kidney transplantation is the preferred renal replacement therapy in children with end-stage renal disease, providing a significant survival advantage over dialysis (1, 2). Most pediatric kidney transplant recipients will eventually develop graft failure, but little is known about the utility of retransplantation in this population or the most advantageous retransplantation practices. To guide transplant practices and improve clinical decision-making among children with end-stage renal disease, we first examined retransplantation practice patterns and outcomes among pediatric kidney transplant recipients (Chapter 1). We found that racial and socioeconomic disparities exist with regard to retransplantation and that excellent graft survival can be achieved with retransplantation despite poor survival of previous grafts. Next, we quantified the changing risk of graft loss after pediatric kidney transplantation across post-transplant age (Chapter 2). We identified a dramatic increase in graft loss during late adolescence and early adulthood, a high-risk window that appears to affect all recipient subgroups and modify the relationship between typical recipient risk factors and graft loss. Next we compared retransplantation outcomes after pediatric kidney transplantation according to order of deceased donor and living donor transplantation (Chapter 3). We found that deceased donor kidney transplantation in pediatric recipients followed by living donor retransplantation does not negatively impact the living donor graft survival advantage and provides similar cumulative graft life compared to living donor kidney transplantation followed by deceased donor retransplantation. Finally, to address limitations of Chapter 3 (namely the difficulty of addressing sensitization risks, aging of the living donor, the high-risk age window, and deceased donor waiting times), we designed a Markov decision process model to compare the relative benefit of undergoing primary deceased donor vs. living donor kidney transplantation for a given pediatric patient with end-stage renal disease with one living donor available (Chapter 4). The results of these studies will be used by patients, nephrologists, and transplant providers to guide retransplantation practices and improve clinical decision-making for children who require kidney transplantation.