508 - Identifying Early Risk Factors and Primary Causes of Seven-day Graft Loss following Pediatric Kidney Transplantation: A 2015–2024 UNOS Registry Analysis

Publication Number: 2494.508

Varin Gupta, Kansas City University - College of Osteopathic Medicine, Kansas City University COM Kansas City, MO, United States; Tyler Sanchez, New York Medical College, Montague, NJ, United States; Sohail Khan, New York Medical College, Touro COM Middletown, NY, United States; Riah Lee, Touro College of Osteopathic Medicine, Touro COM Middletown, NY, United States; Soumith Sanka, Michigan State University COM East Lansing, MI, United States; Yang Yu, George Mason University, Arlington, VA, United States; Meng-Hao Li, George Mason University, Arlington, VA, United States; Naoru Koizumi, George Mason University, Arlington, VA, United States; Jorge Ortiz, garnet health medical center, Touro COM Middletown, NY, United States

Background: Kidney transplantation (KTx) is the treatment of choice for children with end-stage renal disease (ESRD), offering superior survival and quality of life compared with dialysis. Pediatric KTx markedly improves survival in children with ESRD, yet early graft loss (EGL) remains a critical determinant of immediate graft success and long-term survival. Although both EGL and early posttransplant mortality have been well characterized, seven-day graft loss (7DGL) remains limited.

Objective: This analysis aimed to identify primary causes and risk factors for 7DGL, including early mortality following KTx from deceased (DD) and living donors (LD).

Design/Methods: A retrospective cohort analysis of pediatric KTx performed between January 1, 2015, and June 30, 2024, was conducted leveraging the United Network for Organ Sharing (UNOS) database. Recipients who experienced 7DGL or seven-day mortality (7DM) were compared with those achieving graft survival beyond one year. Variables analyzed included donor, recipient, and transplant characteristics. Continuous variables were analyzed utilizing Student's t-test or the Mann-Whitney U test, as appropriate. Categorical variables were assessed with Pearson's χ2 test or Fisher's exact test. Multivariable logistic regression was used to identify factors independently associated with 7DGL and 7DM. A two-sided p-value < 0.05 was considered statistically significant. All analyses were performed in STATA (version 18E; StataCorp LLC, College Station, TX).

Results: Among 6,077 pediatric recipients, 73 (1.2%) experienced 7DGL. Graft thrombosis was the leading cause (61.6%), followed by primary nonfunction (PNF) (26.0%). Four recipients (0.07%) died within seven days (DD, n = 3, 0.07%; LD, n = 1, 0.05%), with all DD deaths occurring in children younger than 10 years (p = 0.036). Recipients with 7DGL had longer dialysis vintage duration (median 718 vs 534.5 days; p = 0.032) and prolonged cold ischemia time (CIT) (mean 12.46 vs. 9.80 hours; p = 0.004). In multivariable modeling, dialysis at registration was associated with lower odds of 7DGL in DD recipients (OR, 0.46; 95% CI, 0.27-0.80; p = 0.006). Each additional hour of CIT increased risk by approximately 5% (OR, 1.05; 95% CI, 1.02-1.08; p = 0.004).

Conclusion(s): 7DGL in pediatric KTx is rare, and primary causes reflect thrombosis and primary nonfunction. Shortening cold ischemia through optimized allocation and refined intraoperative hemodynamic control may lower 7DGL incidence in pediatric recipients.

Primary Causes of Graft Failure and Recipient, Donor, and Transplant Characteristics in Pediatric Kidney Recipients With 7-Day Graft Loss Versus ≥ 1-Year Graft Survival in the Overall Population
Values are presented as mean ± SD for continuous variables and n (% of group) for categorical variables. Abbreviations: 7DGL, 7-day graft loss; BKVAN, BK virus-associated nephropathy; BMI, body mass index; CIT, cold ischemia time; cPRA, calculated panel reactive antibody; DBD; donor after brain death; DCD, donation after circulatory death; DM, diabetes mellitus; GF, graft failure; GFR, glomerular filtration rate; GN, glomerulonephritis; FSGS, focal segmental glomerulosclerosis; HLA, human leukocyte antigen; HNS, hypertensive nephrosclerosis; HTN, hypertension; KDPI, Kidney Donor Profile Index; PKD, polycystic kidney disease; PNF, primary nonfunction; T2DM, type 2 diabetes mellitus
† 'Other' includes American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and Multiracial recipients, combined due to small subgroup counts that could otherwise introduce bias into model estimation.

Primary Causes of Graft Failure and Recipient, Donor, and Transplant Characteristics in Pediatric Kidney Recipients Stratified by Donor Type (Deceased vs Living Donor) With 7-Day Graft Loss Versus ≥ 1-Year Graft Survival
Values are presented as mean ± SD for continuous variables and n (% of group) for categorical variables. Abbreviations: 7DGL, 7-day graft loss; BKVAN, BK virus-associated nephropathy; BMI, body mass index; CIT, cold ischemia time; cPRA, calculated panel reactive antibody; DBD; donor after brain death; DBD; donor after brain death; DCD, donation after circulatory death; DM, diabetes mellitus; GF, graft failure; GFR, glomerular filtration rate; GN, glomerulonephritis; FSGS, focal segmental glomerulosclerosis; HLA, human leukocyte antigen; HNS, hypertensive nephrosclerosis; HTN, hypertension; KDPI, Kidney Donor Profile Index; NA, not applicable; PKD, polycystic kidney disease; PNF, primary nonfunction; T2DM, type 2 diabetes mellitus
† 'Other' includes American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and Multiracial recipients, combined due to small subgroup counts that could otherwise introduce bias into model estimation.

Multivariable Predictors of 7-Day Graft Loss in Pediatric Deceased Donor Kidney Transplant Recipients
Multivariable logistic regression using odds ratios (OR) with 95% confidence intervals (CI) for predictors of 7-day graft loss in the deceased donor cohort of pediatric kidney recipients (n = 4,097; 54 cases, 4,043 controls). Abbreviations: 7DGL, 7-day graft loss; CIT, cold ischemia time;
† Reference group: recipients younger than 10 years of age