*Purpose: Choice of induction agent for pediatric kidney transplantation (KTx) is often based upon patient characteristics and center practice; costs associated with this choice have not been reported. We estimated costs by induction therapy among children undergoing KTx.

*Methods: Retrospective study of merged data from the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry and the Pediatric Health Information System (PHIS) database between 2010-2019. Participants were grouped by induction agent: IL2 RB only, rATG/ALG, and alemtuzumab (ALEM). Unadjusted and adjusted mean standardized index hospitalization costs (IHC) were estimated. Unadjusted IHC were analyzed based upon service category (clinical, imaging, lab, pharmacy, supply, length-of-stay related, other).

*Results: 830 KTx recipients were included: 260 (31%) IL 2RB, 419 (51%) rATG/ALG, 151 (18%) ALEM. Median unadjusted IHC were significantly different among the induction groups (<0.001) with IL 2RB IHC ($170,565) being higher than ALEM ($146,647) and rATG/ALG ($144,146). The costs of service categories were significantly different (<0.001) with the exception of lab costs. Clinical accounted for most of IHC, primarily due to organ acquisition costs. Median clinical costs/percentage due to organ acquisition were $105,610/88.5% (IL 2RB), $92,129/96.8% (ALEM), and 69,185/94.7% (rATG/ALG). Pharmacy costs were $17,219 for rATG/ALG group, $13,340 for IL 2RB, and $4,718 for ALEM. In adjusted analysis, induction agent, donor source, preemptive and primary KTx were not associated with total IHC. Younger age at time of KTx, delayed graft function (DGF), and diagnosis of FSGS were associated with higher IHC (see Table).

*Conclusions: Costs for pediatric KTx are substantial and higher among those with younger age, FSGS diagnosis, and DGF. Although induction agent affects cost across most service categories, it was not associated with overall higher total costs in children.​

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