Outcomes After Declining Increased Infectious Risk Kidney Offers for Pediatric Candidates in the United States.

BACKGROUND: Kidneys from donors at increased risk for disease transmission (IRDs) confer substantial survival benefit in adults, yet the benefit of IRDs to pediatric candidates remains unclear in the context of high waitlist prioritization.

METHODS: Using 2010-2016 OPTN data, we studied 2417 pediatric candidates (age <18) who were offered an IRD kidney that was eventually used for transplantation. We followed candidates from date of first IRD offer until date-of-death or censorship and used Cox regression to estimate mortality risk associated with IRD acceptance vs decline adjusting for age, sex, race, diagnosis, and dialysis time.

RESULTS: Over the study period, 2250 (93.1%) pediatric candidates declined and 286 (11.8%) accepted an IRD offer; 119 (41.6%) of the 286 had previously declined a different IRD. Cumulative survival among those who accepted versus declined the IRD was 99.6% vs 99.4% 1yr and 96.3% vs 97.8% 6yrs post-decision (P = 0.1). Unlike the substantial survival benefit seen in adults (HR = 0.52), among pediatric candidates we did not detect a survival benefit associated with accepting an IRD (adjustedHR:0.791.723.73, P = 0.2). However, those who declined IRDs waited a median 9.6 months for a non-IRD kidney transplant (11.2 months among those <6yrs, 8.8 months among those on dialysis). KDPI of the eventually accepted non-IRD kidneys (median = 13, IQR = 6-23) was similar to KDPI of the declined IRDs (median = 16, IQR = 9-28).

CONCLUSIONS: Unlike in adults, IRDs conferred no survival benefit to pediatric candidates, although they did reduce waiting times. The decision to accept IRD kidneys should balance the advantage of faster transplantation against the risk of infectious transmission.