Pediatric kidney transplant candidates will likely need more than 1 kidney transplant in their lifetime. Whether receiving the first allograft from a living donor (LD) is better than receiving it from a deceased donor (DD) for long-term patient survival remains unclear. A new model suggests that receiving an LD kidney first sequence could be optimal.

Investigators used a decision analytic Markov model to compare the 2 kidney transplant sequence options in recipients aged 3 to 25 years. In option 1 (LD-DD sequence), patients received an LD transplant without going on the waiting list. In the case of allograft failure, patients returned to the waiting list and obtained a DD transplant. In option 2 (DD-LD sequence), patients were initially on the waiting list, received a DD first, and if the allograft failed, received a LD transplant. For option 2, the model incorporated a 10% risk that the LD would no longer be available.

Under most circumstances, the LD-DD sequence resulted in more life-years in pediatric recipients aged 5-9 and 20-24 years compared with the DD-LD sequence, Karthik K. Tennankore, MD, SM, of Dalhousie University, in Halifax, Nova Scotia, Canada, and colleagues reported in JAMA Network Open. In patients within the age groups 10-14 and 15-19 years, the survival benefits were less consistent. The LD-DD sequence was favorable for children in these age groups when eligibility for a second transplant was low or if the living donor was no longer available.

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Even when pediatric patients could have multiple DD kidney transplants, the LD-DD sequence typically provided longer survival, the investigators reported.

There were 41% fewer pediatric living kidney recipients in 2015-2019 compared with 2001-2005. Prioritizing DD kidney transplant for pediatric recipients may have inadvertently reduced LD transplant rates and remaining life-years.

“These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized,” Dr Tennankore’s team wrote. “Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kiberd BA, Vinson A, Acott PD, et al. Optimal sequencing of deceased donor and live donor kidney transplant among pediatric patients with kidney failure. JAMA Netw Open. Published online January 6, 2022. doi:10.1001/jamanetworkopen.2021.42331