A donor risk index for graft loss in pediatric living donor kidney transplantation

Pediatric kidney transplant candidates often have multiple potential living donors (LDs); no evidence-based tool exists to compare potential LDs, or to decide between marginal LDs and deceased donor (DD) kidney transplantation (KT). We developed a pediatric living kidney donor profile index (P-LKDPI) on the same scale as the DD KDPI by using Cox regression to model the risk of all-cause graft loss as a function of living donor characteristics and DD KDPI. HLA-B mismatch (adjusted hazard ratio [aHR] per mismatch= 1.04 1.27 1.55 ), HLA-DR mismatch (aHR per mismatch= 1.02 1.23 1.49 ), ABO incompatibility (aHR = 1.20 3.26 8.81 ), donor systolic blood pressure (aHR per 10 mm Hg= 1.01 1.07 1.18 ), and donor estimated GFR (eGFR; aHR per 10 mL/min/1.73 m 2 = 0.88 0.94 0.99 ) were associated with graft loss after LDKT. Median (interquartile range [IQR]) P-LKDPI was −25 (−56 to 12). 68% of donors had P-LKDPI <0 (less risk than any DD kidney) and 25% of donors had P-LKDPI >14 (more risk than median DD kidney among pediatric KT recipients during the study period). Strata of LDKT recipients of kidneys with higher P-LKDPI had a higher cumulative incidence of graft loss (39% at 10 years for P-LDKPI ≥20, 28% for 20> P-LKDPI ≥−20, 23% for −20 > P-LKDPI ≥−60, 19% for P-LKDPI <−60 [log rank P < .001]). The P-LKDPI can aid in organ selection for pediatric KT recipients by allowing comparison of potential LD and DD kidneys.