Is matching for human leukocyte antigen-DR beneficial in pediatric kidney transplantation?

This Practice Point commentary discusses the findings and limitations of a report by Gritsch et al., in which the authors concluded that human leukocyte antigen (HLA)-DR-mismatched kidneys from deceased donors aged 35 years or less are suitable for use in pediatric patients. We highlight the issues to be considered before adopting such an allocation policy. Gritsch et al. reported that the 5-year survival rates of grafts with zero HLA-DR mismatches were identical to those of grafts that were completely mismatched for HLA-DR; however, the report did not provide information about the immunosuppressive regimens used or the frequency of rejection episodes and their treatment. Children who receive HLA-DR-mismatched kidneys will ultimately be exposed to more-intensive immunosuppression in order to overcome the potentially increased risks of acute rejection, graft failure and sensitization. In spite of recent improvements in immunosuppressive therapy, we believe that HLA matching remains crucial for the survival of kidney transplants.