Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
JAMA Netw Open. 2022 Jan 4;5(1):e2142331. doi: 10.1001/jamanetworkopen.2021.42331.
In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known.
To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence).
DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure.
Kidney transplant sequences of LD-DD vs DD-LD.
Difference in projected life-years between the 2 sequence options.
Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity.
These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.
在美国，活体供者（LD）肾移植率在儿科受者中下降。患有肾衰竭的儿科患者在其一生中可能需要不止一次肾移植，但最佳移植顺序（即先进行已故供者[DD]移植，然后进行 LD 移植，或反之）尚不清楚。
确定儿科受者是否应先接受 DD 同种异体移植物，然后再接受 LD 同种异体移植物（DD-LD 序贯），或先接受 LD 同种异体移植物，然后再接受 DD 同种异体移植物（LD-DD 序贯）。
设计、设置和参与者：本决策分析模型检查了美国肾脏数据系统 2019 年报告中纳入的等待肾移植、接受移植或发生移植物失败的美国肾衰竭儿科患者。
LD-DD 与 DD-LD 的移植顺序。
两种序列选择之间预计寿命年数的差异。
在纳入分析的患者中，与 DD-LD 序列相比，5 岁（1.82[95%CI，0.87-2.77]）和 20 岁（2.23[95%CI，1.31-3.15]）患者的 LD-DD 序列提供了更多的净寿命年数。10 岁（0.36[95%CI，-0.51 至 1.23]额外寿命年数）和 15 岁（0.64[95%CI，-0.15 至 1.39]额外寿命年数）患者的净结局无显著差异。然而，对于 10 岁的患者，如果第二次移植的资格较低（2.09[95%CI，1.20-2.98]额外寿命年数）或 LD 不再可用（2.32[95%CI，1.52-3.12]额外寿命年数），则 LD-DD 序列更为有利。对于 15 岁的患者，如果第二次移植的资格较低（1.84[95%CI，0.96-2.72]额外寿命年数）或 LD 不再可用（2.49[95%CI，1.77-3.27]额外寿命年数），则 LD-DD 序列更为有利。无法获得多次 DD 移植并不能弥补错失 LD 机会的损失。
这些发现表明，在过去 20 年中，活体供肾移植在儿科受者中的使用减少应受到仔细审查。鉴于未来受者再次移植资格的不确定性和未来 LD 移植的可用性，LD-DD 序列可能是更好的选择。这种首先进行 LD 移植的策略不仅将使儿科受者受益，而且还可以让那些没有 LD 选择的人使用 DD 肾脏。
