*Purpose: Women with end-stage renal disease have lower access to deceased donor kidney transplantation than men. Expanding the donor pool to include kidneys from very small pediatric donors, an underutilized source, may help narrow the gap in access. In our study, we analyzed outcomes of kidney transplantation from small pediatric donors to determine if utilization of kidneys from very small donors may help reduce the sex disparity in access to deceased donor kidney transplantation.

*Methods: We performed a retrospective analysis of deceased donor kidney transplant recipients from pediatric donors weighing <20 kg between 2010 and 2021 at our institution. We compared long-term graft survival by recipient sex and donor weight (“very small” <10 kg versus “small” 10 to 19.5 kg) using a weighted log-rank test.

*Results: Of the 327 total patients, 162 (49.5%) were female. The median (range) age was 51 (7 – 76) years with the majority (320) being adults, ages 18 to 76 years. There were 215 (65.7%) patients who received transplantation from “very small” donors weighing < 10 kg (range 1.9 to 9.4 kg), and the remaining 112 (34.3%) patients received kidneys from “small” donors (donor weight 10.0 to 19.0 kg). The donor age range was 3 days to 11 years. Grafts were implanted either en bloc (267 patients) or single (60 patients) into the iliac fossa. Significantly more very small donor kidneys were transplanted into women (57%), while more small donor kidneys were transplanted into men (64%) (p < 0.001). Overall long-term graft survival for the entire cohort was excellent with a median follow up time of 6.7 years. There was no difference in graft survival of female vs male recipients of either very small (Figure 1) or small pediatric donor kidneys.

*Conclusions: More women were selected for kidneys from very small pediatric donors with excellent long-term outcomes. Increasing utilization of this donor source directed to women may be a means to helping address the sex disparity in access to deceased donor kidney transplantation.

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