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TOPLINE:

In paediatric kidney transplant recipients, the risk for graft failure increased with each subsequent transplantation. After the second transplant, older donor age, transplantation from a deceased donor, shorter survival of the primary graft in non-sensitised recipients, higher panel-reactive antibody (PRA) levels, and an increasing number of human leucocyte antigen DR (HLA-DR) mismatches predicted a higher risk for graft failure.

METHODOLOGY:

• Researchers analysed data from a European registry to determine the incidence and risk factors for graft failure and death after repeat kidney transplantation in paediatric recipients across Eurotransplant countries.
• They included 4527 primary paediatric kidney transplant recipients (median age, 11 years; 41% girls), of whom 1155 underwent a second, 259 a third, and 41 a fourth kidney transplantation.
• The median follow-up duration for the first, second, third, and fourth kidney transplantation was 8.83, 6.67, 5.75, and 5.58 years, respectively.
• The probability of graft failure (the need for dialysis or retransplantation) and death with a functioning graft was analysed in kidney transplantation recipients.
• Patient data collection included recipient sex and age; country; transplantation dates; PRA levels; primary kidney disease; graft failure dates; donor source, age, and sex; and the number of HLA mismatches.

TAKEAWAY:

• The risk for graft failure increased with each subsequent kidney transplant, with 5-year rates of 15% after the first, 24% after the second, 30% after the third, and 40% after the fourth transplant.
• The risk for graft failure or death with a functioning graft was the highest in the first month after primary kidney transplantation and increased even further after each subsequent transplantation.
• After the second transplant, transplantation from deceased donors, older donor and recipient age, shorter survival of the first graft in non-sensitised recipients, higher PRA levels (1%-100%), and an increasing number of HLA-DR mismatches were associated with an increased probability of graft failure and death with a functioning graft.
• Transplants performed in more recent years were also associated with better survival outcomes.

IN PRACTICE:

"Each subsequent kidney transplantation in pediatric recipients carried a higher risk of GF [graft failure], particularly in the first months post-transplant. After the second transplantation, older calendar year of KTx [kidney transplantation], deceased donor (DD), older donor and recipient age, and increasing HLA-DR mismatches were associated with a higher predicted GF and death with functioning graft," the authors wrote.

"In DD kidney allocation schemes, 2 HLA-DR mismatches should be avoided," they added.

SOURCE:

This study was led by Ferran Coens, Ghent University Hospital, Ghent, Belgium. It was published online on August 07, 2025, in Pediatric Nephrology.

LIMITATIONS:

This study had substantial missing data for HLA mismatches in living donor transplants, limiting the analysis of HLA mismatches to deceased donor kidney transplant recipients alone. Additionally, the analysis did not adjust for certain relevant peri- and post-transplant predictors of graft failure, such as cold and warm ischaemia time, socioeconomic status, and allograft rejection. 

DISCLOSURES:

The registry involved in this study received funding through a grant from the Dietmar Hopp Stiftung, the European Society for Paediatric Nephrology, the German Society for Pediatric Nephrology, and other sources. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.