Background: Pediatric deceased donor kidneys (DDK) are an important source of organs for kidney transplantation although there is no consensus about 1) which candidates are best suited to be transplanted with pediatric DDK; and 2) whether to allocate DDK from young pediatric donors en-bloc or as single kidney transplants (SKT). Purpose: 1) Report current allocation patterns of pediatric DDK; 2) Characterize graft performance of pediatric donor subsets and 3) analyze recipient factors that influence pediatric DDK graft survival. Methods: Data on all kidney-alone DDK transplants from 1/1/00-12/31/10 were collected from the UNOS Standard Transplant Analysis and Research Files dataset. Donors were categorized by age groups, with 1-5 year old (yo) donors being further characterized by En-Bloc or SKT status. Graft survival plots were made using the Kaplan-Meier method and comparisons between age groups were made with the log rank test. The primary outcome was actuarial 5-year graft survival rates (5-yr GS). Cox regression analyses controlling for recipient factors were performed to confirm unadjusted results. Results: Pediatric DDK currently represent more than 10% of all DDK with 90% of pediatric DDK being transplanted into adult recipients, 37% of which are transplanted into adults > 50. Almost all 0 yo DDK are transplanted en bloc, have a high risk of graft failure (18%) in first 100 days post transplant, but subsequently have a reduced risk of graft failure resulting in a 66% 5-yr GS which is comparable to that of 50-60 yo kidneys (63% 5-yr GS). SKT from 1-5 yo (69% 5-yr GS) should be considered comparable to 35-49 yo DDK (69% 5-yr GS) and 6-9 yo DDK (71% 5-yr GS). En Bloc organs from 1-5 yo (76% 5yr GS) should be considered optimal and equivalent to older children and young adult (10-34 yo) DDK (76% 5-yr GS). Cox regression analyses confirmed independence from current recipient distribution of pediatric DDK. Conclusion: Given current outcomes from DDK grafts, transplant teams should be more willing to accept young pediatric kidneys for adult candidates in particular when the donor is > 1 yo. Whether the better outcomes of en bloc kidneys versus SKT from 1-5 year old donors justify transplanting half as many candidates needs to be considered in future policy revisions.

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