Living donor kidney transplantation in pediatric recipients.

Living donor kidney transplantation has increased in frequency in pediatric patients, accounting for 43% of cases performed between 1987 and 1991, and 52% of cases performed between 1987 and 2004 in North America. Patient survival has remained excellent over the years, and is currently over 96% at five years. Graft survival has improved over the years, and is currently over 95% at one year. Rejection rates have fallen over the years, and are currently <25% overall, with selected centers having very low rejection rates. The reasons for these improved outcomes are likely related to improvements in maintenance immunosuppression, which include a transition from cyclosporine to tacrolimus-based regimens, and from azathioprine to mycophenolate mofetil or sirolimus as adjunctive agents. Steroid withdrawal and steroid avoidance are beginning to be utilized by several centers, with excellent early outcomes. Finally, while there may be center effect/learning curve issues involved, the type of donor nephrectomy has recently been shown to influence early outcomes, particularly in very young recipients.