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Youth who spent more time with an estimated glomerular filtration rate (eGFR) at or below levels recommended for transplant were more likely to receive preemptive or living donor transplants than those with shorter durations of low eGFR, according to a new analysis of over 300 individuals.

Transplant is associated with longer survival and improved quality of life for children with advanced kidney disease. However, only about 25% of children with chronic kidney disease (CKD) receive living donor transplants, and fewer than half avoid dialysis before transplant (preemptive transplant), said senior author Sandra Amaral, MD, associate professor of pediatrics and epidemiology at the Perelman School of Medicine, University of Pennsylvania in Philadelphia.

“Referring children early for transplant is a potential actionable intervention to optimize transplant access and outcomes,” Amaral told Medscape Medical News.

Previous research has shown that non-Hispanic Black and Hispanic youth are less likely than non-Hispanic White youth to receive preemptive or living donor kidney transplants. However, the impact of differences in kidney disease progression on these disparities has not been well studied, Amaral noted.

“To avoid dialysis and identify a living donor, a child must be referred for transplant early to allow time for planning and living donor evaluation,” she said.

The study was published in Pediatric Nephrology.

Examining eGFR’s Impact

The researchers, therefore, examined whether time spent with advanced kidney disease was associated with the likelihood of receiving a preemptive or living donor transplant, as well as the role of race and ethnicity.

The study included 333 children and teens (35% female; median age, 11 year) with CKD. Of these, 160 were White, 72 Black, 65 Hispanic, and 36 from other ethnicities. The median time with low eGFR (defined as between 10 mL/min/1.73 m² and 30 mL/min/1.73 m²) was 28.8 months.

Overall, 77% of youth were preemptively waitlisted before requiring dialysis, 10% were waitlisted after starting dialysis, and 45% received a preemptive transplant. Preemptive transplant was more common among White children than Black children (56% vs 24%).

Compared with White patients, Black patients spent a mean of 6.5 fewer months with low eGFR (95% CI, -11.5 to -1.4; P = .01). Time with low eGFR did not differ significantly across other groups.

Each additional year spent with low eGFR was associated with a higher likelihood of receiving a living donor transplant (odds ratio [OR], 1.42; 95% CI, 1.21-1.67) and of undergoing preemptive transplant without the need for dialysis (OR, 1.45; 95% CI, 1.24-1.70), but not with an increased likelihood of preemptive waitlisting (OR, 0.96; 95% CI, 0.83-1.11).

“These findings highlight the importance of early referral for transplant, especially for children who are likely to lose kidney function quickly, with special attention to early referral for Black children,” Amaral said. “Avoiding dialysis and finding living donors takes time, and early referral is an important part of optimizing kidney transplant access and outcomes for children.”

Looking ahead, additional research is needed to identify barriers to timely transplantation and living donation that were not captured in this study, Amaral noted. These may include family-level barriers such as financial or transportation constraints, as well as donor eligibility issues.

The Value of Early Referral

“This study addressed an important gap by examining how time spent with low eGFR in advanced CKD affects access to kidney transplantation in youth, in the absence of national data on pediatric eGFR trajectories to guide referral timing,” said Marissa Lipton, MD, clinical assistant professor of pediatrics and a pediatric nephrologist at Hassenfeld Children’s Hospital at NYU Langone Health, New York City, who was not involved in the study.

The finding that longer time with low eGFR increased transplant likelihood suggests that factors beyond waitlisting, such as the time required for transplant preparation and identifying a living donor, play a critical role in achieving preemptive transplantation, Lipton told Medscape Medical News.

“Earlier transplant referral is critical, as each additional year with low eGFR substantially increased odds of preemptive transplantation,” Lipton said. Because preemptive transplants were largely driven by living donation (60% of cases), efforts to identify potential donors should begin as early as possible.

Although the study relied on data from specialized centers, which may limit generalizability, and lacked details on barriers to transplantation, Lipton noted that the findings suggest that waitlisting alone is insufficient to ensure timely transplant in pediatric CKD.

“Early referral may be particularly important for Black youth, who receive fewer living donor transplants and are at risk for faster CKD progression,” she said.

Further research is needed to define optimal referral timing and better understand barriers to successful transplantation, particularly living donor processes, Lipton added.

The study was supported by the National Institutes of Health. The study authors and Lipton reported having no relevant financial conflicts.