*Purpose: Very low bodyweight pediatrics are rarely chosen as donors because of potential higher risk for complications such as early allograft thrombosis, and possible latter hyperfiltration injury. We evaluated our transplants from the small donors focusing on the complications.

*Methods: We retrospectively studied 31 cases of en-bloc kidney transplantation from pediatrics weighing less than 5kg between 2014-2019. All allografts were preserved by static cold storage. Induction immunosuppression consisted of thymoglobulin+methylprednisolone, and maintenance of tacrolimus+mycophenelate mofetil+prednisone. 19/31 were administered with low molecular weight heparin, while 12/31 had no postoperative anticoagulation. All recipients were followed up for at least 1 year.

*Results: 8 recipients (25.8%) including 2 graft venous thrombosis, 4 graft arterial thrombosis, 1 primary non-function, and 1 acute rejection had early graft loss in two weeks after transplant. Graft thrombosis morbidity in the anticoagulation treated group is even higher than the non-anticoagulation group (26.3% vs 8.3%, p>0.05). The remaining 23 recipients had satisfactory renal perfusion and renal function recovery. Their proteinuria (PU) morbidity is 30.4%, 21.7%, 21.7% at 3, 6, 12 months after transplant respectively. And the recipient/donor body weight ratio of PU and non-PU recipients were not significantly different (p>0.05) at these time points. Overall delayed graft function (DGF) morbidity is 39.1% (9/23), in addition the DGF recipients had significantly higher (20.8±9.9 vs 13.3±2.9, p<0.05) recipient/donor body weight ratio than the ones without DGF.

*Conclusions: Kidneys from neonatal donors can achieve promising outcomes with proper surgical procedures and perioperative managements. However, there was a learning curve for utilizing these small grafts. Postoperative anticoagulation did not contribute to prevention of graft thrombosis. Higher recipient/donor body weight ratio seemed to be related to higher possibility of DGF but not proteinuria. Future expanded studies are warranted to determine the reliability of our protocol of using such small donors and long-term recipient outcomes.

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