*Purpose: Kidneys from small donors (SDK, donor weight <20kg) have preferably been allocated en bloc to adult recipients in the past. Reports about thrombotic complications and poorer outcomes of kidney function in the first year following SDK transplantation (SDTx) limit their use in smaller children, particularly as single grafts. The purpose of our study was to evaluate the outcome of SDTx in a specialized pediatric transplant centre.

*Methods: We performed a retrospective transplant data analysis from our centre between 2008 and 2018 (mean observation time 6.4+3.7years) when SDTx was performed in 40 children (mean age 5.4+1.4 years, 20 male, 20 female, 38 single grafts, 10 with donor weight <10kg).

*Results: Three patients with syndromatic underlying disease and preserved kidney function died because of other, non-Tx-related reasons. Only few perioperative complications (thromboses despite early heparinization, n=3) were observed, leading to graft loss in one patient. Early and long-term kidney function remained excellent (GFR 76+21 after 1 month vs. 111+33ml/min/1.73m² after 5 years) in most patients and only three patients presented a delayed graft function. Graft volume increased significantly within 5 years (mean volume 69+21 initially vs. 111+33 ml after 5 years; p<0.0001) and reached normal kidney volume ranges of healthy children. Despite the use of steroids and syndromatic underlying diseases, patients showed a catch-up-growth to normal range (SDS for height -2.06+1.6 prior Tx to +1.6+1.5 within 5 years). Stratification by recipient age and donor weight showed even better results in young recipients (<3years) and <10kg donors. Gain of GFR and graft volume was even higher in patients with very small donor or recipient size, regardless a reduced donor/recipient weight ratio.

*Conclusions: We present encouraging outcome data from kidney donors <20 kg and postulate that SDTx should preferably be considered in experienced centres for small pediatric recipients.

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