*Purpose: Kidney transplantation (KTx) is considered more technically challenging in small children, incurring a higher risk of potential surgical and vascular complications. Intraperitoneal approach of KTx has traditionally been thought to be technical option for low body weight recipients. More recently, extraperitoneal approach has been used more often, but there is not yet a unified view whether which one to choose. The aim of this study was to establish whether there is a difference in long-term outcome and surgical complications after pediatric KTx dependent on the surgical approach.

*Methods: We performed a retrospective cohort study on pediatric kidney transplant recipients, weighting less than 15 kg, who received their first living-related kidney transplant between January 1987 and December 2015. Patients were divided into two groups according to intraperitoneal approach (group 1) or extraperitoneal approach (group 2), and clinical data were extracted from the medical records.

*Results: Among the 326 children who underwent first living-donor KTx during the study period, 100 children (30.7%) were performed KTx with body weight <15 kg. The median duration of follow-up was 14.1 years (IQR 9.0-19.2). Baseline demographic data were similar between group 1 (n=62) and group 2 (n=38) except that age (4.3±1.6 vs 4.9±1.1 years, p=0.04), body weight (11.7±1.7 vs 12.8±1.4 kg, p<0.001), tacrolimus (42% vs 63%, p=0.04) and basiliximab (29% vs 82%, P<0.001), were significantly lower in group 1. Overall, early surgical complications were observed in only group 1. There were 11 surgical complications in 10 recipients within 30 days post-transplant. Vascular complications occurred in three patients, with subsequent early graft loss. Bowel obstruction was the most frequent late complications. Patient survival at 10 years was 95% and 97% in group 1 and group 2, respectively (p=0.82). Graft survival at 10 years was 89% and 92% in group 1 and group 2, respectively (p=0.42). No significant difference in acute rejection within 1 year post-transplant incidence was found between the groups (50% vs 30%, p=0.06). Estimated glomerular filtration rate at 10 years post-transplant was comparable between the groups (48.9±15.7 vs 55.4±17.2 ml/min/1.73m², respectively, p=0.20).

*Conclusions: Extraperitoneal KTx in low body weight children was safe and technically feasible. From our series, there were many surgical complications in intraperitoneal KTx, although there was no difference in long-term patient and graft survival, graft function between surgical approaches.

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