Purpose: To evaluate the impact of Share-35 implemented 9/30/05 by the United Network for Organ Sharing (UNOS) that gives pediatric patients with end stage renal disease high priority in deceased donor kidney transplantation (DDKT) allocation. Methods: We analyzed waitlist data from the UNOS Standard of Transplant Analysis and Research dataset between 9/30/00-9/30/05 (pre-Share 35); and 10/1/05-10/1/10 (post-share-35). We examined changes in the demographics of the donor and recipient pools in the 2 eras. We also used survival analysis to assess the impact of Share-35 on graft survival with respect to recipient age, donor age, and HLA mismatch. Finally, we compare how quickly new waitlist registrants in calendar year 2002 (pre-Share-35) and 2007 (after most pediatric candidates with accumulated waiting time post-share-35 were transplanted). Results: Between the 2 eras, there is an increase in the % of pediatric candidates who identify as Hispanic with a similar decrease in the % who identify as white whereas the % who identify as blacks and candidate gender distribution remained constant. The median waiting time decreased from 204 to 150 days between the 2 eras (p<0.001). In 2007, 58% of new registrants to the kidney waitlist received a transplant within 6 months compared to 44% of new registrants in 2002 (p<0.0001). Similar to previous studies, we demonstrate that 27% less living donations occur following Share-35 (p<0.0001) with African Americans showing the greatest reduction (p<0.0005). In contrast, Share-35 led to a 51% increase in DDKT from era 1 to era 2 (p<0.0001). As a result of Share-35, only 42 (1.7%) pediatric recipients received organs from deceased donors age > 35 years compared to 495 (30%) pediatric recipients who received older organs in the 5 years prior to Share-35 (p<0.0001). There was an increase in mean HLA mismatch in DDKT (4.2 to 4.5 in pre- and post-Share-35 p<0.001), with more than twice as many 6-mismatch transplants being done (263 vs. 537). There was no significant effect on DDKT graft survival nor on overall graft survival from all donors (both living and deceased) despite the decrease proportion of living donor transplants in era 2. Conclusions: Share-35 increased the number of optimal aged deceased donor kidneys and reduced waiting time to DDKT. Despite increased HLA mismatching and decreased living donation, overall graft survival is not affected.

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