Kidney transplantation is the preferred treatment for pediatric end stage renal disease (ESRD), and preemptive transplantation may reduce morbidity and mortality. In the pediatric population, prior single-center studies have demonstrated equivalent or superior outcomes for patients receiving preemptive transplants versus those transplanted following dialysis, but graft survival has not been examined among the national pediatric recipient population.

We examined the rate of graft failure and mortality among patients who had preemptive versus non-preemptive renal transplant among the national pediatric (< 18 yrs) ESRD population using United States Renal Data System (USRDS) data from 2000-2009. Kaplan-Meier methods and Cox models examined the adjusted effect of preemptive transplant on graft failure.

Among 6,658 pediatric kidney transplant recipients over the 10-year study period, 14.4% of patients experienced graft failure and 3.0% died. The rate of graft failure (HR=0.43; 95% CI: 0.35-0.52) and mortality (HR=0.46; 95% CI: 0.31-0.69) among patients who received a preemptive transplant was more than two-fold lower than patients who did not receive a preemptive transplant. After adjusting for demographic, clinical, and transplant factors, the benefit of preemptive transplant remained significant for both graft failure (HR=0.63; 95% CI: 0.51-0.80) and mortality (HR=0.59; 95% CI: 0.38-0.92).

Pre-transplant time on dialysis is one of the strongest modifiable risk factors for renal transplant outcomes and preemptive transplantation entirely circumvents dialysis and its potential complications. Here we document a marked increase in graft survival and decrease in mortality rate for pediatric ESRD patients receiving preemptive renal transplantation, suggesting it is a superior treatment modality for pediatric renal failure.

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