*Purpose: In 12/2014, the new Kidney Allocation System (KAS) assigned allocation priority to highly sensitized (HS) recipients while maintaining access to donors for pediatric patients (peds). Peds receive priority only for KDPI<35% donors, but at a level below HS candidates. We assessed the impact of the KAS on peds transplants.

*Methods: Using OPTN/UNOS data, we assessed: a) temporal trends in the peds waitlist (WL) and transplants; b) KDPI distribution by donor age; and c) distribution of pediatric donors (age<18) in the pre-KAS (1/1/2010-12/3/2014) and post-KAS eras (12/4/2014-9/7/2018).

*Results: The number of waitlisted peds increased from 1197 on 1/1/2010 to 1601 on 1/1/2018 (Fig 1). KDPI is elevated in donors≤10 years (Fig 2). Peds received a similar percentage of pediatric KDPI<35% donors pre- and post-KAS, but substantially less pediatric KDPI ≥35-85% donors post-KAS, which appeared to be re-directed to HS recipients. HS recipients received an increase from 1.8% of pediatric KDPI ≥35-85% donors pre-KAS to 9.3% post-KAS (Fig 3).

*Conclusions: Because KDPI in pediatric donors tends to be ≥35%, peds do not receive enough allocation priority for these donors in the KAS, which are now preferentially allocated to adult HS recipients. In contrast to the recent decline in size of the adult kidney waitlist, the pediatric waitlist has grown. We propose giving peds higher allocation priority over HS patients for all pediatric donors with KDPI<85%. Considering that peds represents only a small percentage of the waitlist, we believe that this change will have little impact on adult and HS candidates, but will give pediatric patients substantial advantage in obtaining the ‘best kidneys’.

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