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

Bowring, Mary G. MPH1; Jackson, Kyle R. MD1; Wasik, Heather MD2; Neu, Alicia MD2; Garonzik-Wang, Jacqueline MD, PhD1; Durand, Christine MD3; Desai, Niraj MD1; Massie, Allan B. PhD, MHS1,4; Segev, Dorry L. MD, PhD1,4,5

doi: 10.1097/TP.0000000000002674
Original Clinical Science—General

Background. Kidneys from infectious risk donors (IRD) confer substantial survival benefit in adults, yet the benefit of IRD kidneys to pediatric candidates remains unclear in the context of high waitlist prioritization.

Methods. Using 2010–2016 Scientific Registry of Transplant Recipients data, we studied 2417 pediatric candidates (age <18 y) who were offered an IRD kidney that was eventually used for transplantation. We followed candidates from the date of first IRD kidney offer until the date of death or censorship and used Cox regression to estimate mortality risk associated with IRD kidney acceptance versus 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 kidney offer; 119 (41.6%) of the 286 had previously declined a different IRD kidney. Cumulative survival among those who accepted versus declined the IRD kidney was 99.6% versus 99.4% and 96.3% versus 97.8% 1 and 6 years post decision, respectively (P = 0.1). Unlike the substantial survival benefit seen in adults (hazard ratio = 0.52), among pediatric candidates, we did not detect a survival benefit associated with accepting an IRD kidney (adjusted hazard ratio: 0.791.723.73, P = 0.2). However, those who declined IRD kidneys waited a median 9.6 months for a non-IRD kidney transplant (11.2 mo among those <6 y, 8.8 mo among those on dialysis). Kidney donor profile index (KDPI) of the eventually accepted non-IRD kidneys (median = 13, interquartile range = 6–23) was similar to KDPI of the declined IRD kidneys (median = 16, interquartile range = 9–28).

Conclusions. Unlike in adults, IRD kidneys 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.

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD.

3 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

4 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.

5 Scientific Registry of Transplant Recipients, Minneapolis, MN.

Received 28 November 2018. Revision received 6 February 2019.

Accepted 6 February 2019.

M.G.B. and K.R.J. contributed equally to this work.

The authors declare no conflicts of interest.

This work was supported by grant numbers F32DK113719 (K.R.J.), K23DK115908 (J.G.-W.), T32DK007732 (H.W.), K01DK101677 (A.B.M.), and K24DK101828 (D.L.S.) from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr C.S. was supported by the Division of Intramural Research, National Cancer Institute (grant K23CA177321-01A1).

M.G.B. and K.R.J. participated in research design, data acquisition, statistical analysis, writing of the manuscript, and editing of the manuscript. H.W. and A.N. participated in research design and comprehensive editing of the manuscript. J.G.-W., C.D., and N.D. participated in research design, analytical approach, and comprehensive editing of the manuscript. A.B.M. contributed to data analysis and analytical tools, research design, and comprehensive editing of the manuscript. D.L.S participated in research design, contributed analytical tools, and comprehensively edited the manuscript.

Correspondence: Dorry L. Segev, MD, PhD, Department of Surgery, Johns Hopkins Medical Institutions, 2000 E Monument St, Baltimore, MD 21205. (

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