Introduction: United States allocation policies currently place less emphasis on HLA matching in pediatric kidney transplant candidates to minimize dialysis time. The impact these policies may have on pediatric recipients following graft failure has not been extensively examined.

Methods: Using the SRTR database, we examined HLA sensitization after graft loss, rates of re-transplantation, time to re-transplantation, and re-graft survival of all pediatric primary kidney transplant recipients <18 years old transplanted 1990-2008, stratified by HLA DR mismatch (MM) of first and second kidney transplant.

Results: Of 11,916 pediatric primary kidney transplant recipients, 2,704 were re-listed after first graft failure. 1,847 received a re-transplant, and 857 remained on the waiting list. Mean %PRA increased from 6% to 45% for those re-transplanted and from 8% to 76% for those remaining on the waiting list. The degree of sensitization, proportion achieving re-transplantation, and waiting time to re-transplant were all associated with DR MM at first kidney transplant. The proportion of patients who underwent re-transplantation was 71% in those with 0-1 DR MM with first transplant compared to 55% in those with 2 DR MM at first transplant (p<0.001). Mean waiting time to re-transplant in those with prior 2 DR MM was 23 months vs. 19 months in those with 0-1 DR MM (p=0.018). On multivariable analysis, 2 DR MM status at first transplant was associated with a 20% reduction in the hazard of receiving a re-transplant (hazard ratio 0.80 for 2 vs. 0-1 DR MM, p<0.001). First and second DR MM significantly impacted re-graft survival (Figure 1). In those with 2 DR MM at first transplant, five-year re-transplant graft survival was inferior even in those with 0-1 DR MM at second transplant (57%), vs. 70% in those with 0-1 DR MM at both first and second transplant (p=0.005).

Conclusion: In pediatric recipients, increasing number of initial HLA DR mismatches is associated with HLA sensitization, longer waiting time, decreased rate of re-transplant, and decreased re-graft survival. Consideration of DR matching at first transplant may mitigate these risks.

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