Outcomes of En Bloc Kidney Transplantation From Small Pediatric Donors to Adult Recipients: A Nationwide Multicenter Retrospective Study

Rationale & Objective The global suitable donor kidney shortage remains a major challenge for kidney transplantation. En bloc kidney transplantation (EBKT) using kidneys from small pediatric donors offers a potential strategy for expanding the deceased donor pool; however, robust nationwide multicenter outcome data are scarce. This study evaluated pediatric-donor EBKT's safety and outcomes in adult recipients using national registry data. Study Design Multicenter retrospective cohort study Setting & Population Adult small pediatric-donor EBKT recipients (n = 27) from four transplant centers in the Netherlands Outcomes The primary endpoint was death-censored graft survival. The secondary endpoints included patient survival, serum creatinine levels, and postoperative complications. Analytical Approach Recipients were compared with 106 matched standard deceased-donor kidney transplantation (SDKT) recipients. Subgroup analyses were performed according to center experience (high-volume vs. low-volume centers) and donor body weight (≤10 kg vs. >10 kg). Results Death-censored graft survival at 1, 5, and 10 years was 0.81 (0.67–0.98), 0.76 (0.60–0.95), and 0.76 (0.60–0.95), respectively, for EBKT and 0.91 (0.86–0.97), 0.86 (0.79–0.94), and 0.77 (0.66–0.90), respectively, for SDKT, with no statistically significant differences. Patient survival was comparable between the groups. EBKT using donors weighing >10 kg demonstrated higher 1-year graft survival than donors weighing ≤10 kg, although this difference was not statistically significant (0.88 [0.73–1.00] vs. 0.72 [0.49–1.00], P=0.34). Postoperative complication rates did not differ significantly between the EBKT and SDKT recipients. Limitations The retrospective design introduces potential selection bias and unmeasured confounding factors. The absolute number of EBKT cases was limited, reducing the statistical power. Transplant center expertise was assessed based on procedural volume rather than detailed surgeon-level experience or technical variables. Conclusions Small pediatric-donor EBKT is safe and effective, demonstrating graft survival comparable to that of SDKT, and has the potential to expand the kidney donor pool.