*Purpose: Allograft rejection often results in increased hospital and medical resource utilization. Pediatric kidney transplant recipients (KTR) are at risk for psychosocial stressors, nonadherence to their medical regimen, and rejection episodes. We investigated allograft rejection in a pediatric and young adult KTR cohort and the related use of transplant psychologist resources.

*Methods: This retrospective cohort study investigated pediatric KTR transplanted between January 2016 and November 2020. Data collected included baseline demographic and clinical information, immunosuppression regimen (induction and maintenance), rejection episodes (classification and severity), graft survival, and number of patient visits (in-person or virtually) with the transplant psychology team. Cost per psychologist visit was estimated based on average billing reimbursements at our institution.

*Results: 111 pediatric/young adult KTR were included during the 5-year study period (M_age=12.32, 55% female, 71.2% White). 20 (18%) patients experienced 30 acute rejection episodes (median time to first rejection 369 days; IQR 245-669). Eight (7.2%) patients experienced 2 or more rejections. 106 (95.5%) patients were seen post-transplant (after hospital discharge) by transplant psychology. Patients who experienced acute rejection utilized significantly more mental health resources than those who did not reject (median 3 vs 8.5 transplant psychology sessions; IQR 2-10.2, p: 0.001), resulting in an increased cost of $2,321 and 220 minutes in direct patient care per patient, plus additional time required to coordinate the unique mental health needs of each patient.

*Conclusions: Integrated behavioral health support, specifically targeting non-adherence and post-transplant stressors, is critical for successful transplant outcomes among pediatric KTR. Acute rejection among pediatric KTR may result in increased stress in a patient population already prone to psychosocial instability. Further, the cost of acute rejection extends beyond the economic and social impact of treating just its medical sequelae, to allocation of scarce mental health resources within transplant. Availability of transplant psychologists improves accessibility of psychological supports in this high-risk population, and programs should ensure their patients have access to this important service.

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