The impact of donor/recipient age difference and HLA mismatch on graft outcome in pediatric kidney transplantation.

Background: Understanding the relationship between the factors that influence long-term kidney transplant survival remains a key priority for pediatric nephrologists. We assessed the relative impact of donor/recipient age difference and HLA matching on long-term graft outcomes.

Methods: We conducted a retrospective cohort study of pediatric and adolescent recipients who received a primary kidney transplant in Australia and New Zealand between January 1, 1990, and December 31, 2015. The primary outcome was graft survival analyzed by Kaplan-Meier method.

Results: During the 26-year period, 1134 primary (395 DD and 739 LD) kidney transplants were performed in recipients less than 20 years of age. The median follow-up time was 10.2 years. Overall, 405 patients (35.7%) lost their transplant with graft survival 93.8% at 1 year, 82.5% at 5 years, 65.8% at 10 years, and 49.9% at 15 years post-transplant. There was consistently higher graft loss of DD kidneys as compared to LD kidneys at each time point. Both increasing donor/recipient age difference (aHR 1.11 per 10 years; 95% CI, 1.02-1.20; P = 0.009) and increasing HLA mismatch (aHR 1.20 per mismatch; 95% CI, 1.10-1.30; P < 0.001) were associated with decreased graft survival.

Conclusions: Donor/recipient age difference and HLA matching are important factors influencing long-term graft outcomes in pediatric kidney transplantation. HLA mismatch remains a strong predictor of graft loss. For patients without the option of a LD, we suggest that the degree of HLA mismatch should not be discounted as part of the decision-making process of organ allocation.