The mortality risk with graft function has decreased among children receiving a first kidney transplant in the United States

Mortality has decreased in children with end-stage kidney disease. Decreases in mortality during dialysis and improved graft survival contributed to this improvement. However, it is unknown whether rates of death with graft function have also improved. We measured this in first transplant recipients under 21 years of age registered in the US Renal Data System. Cox models were used with a time-dependent renal replacement therapy modality variable to estimate the hazard ratios (HRs) for death with graft function associated with a 1-year increment in the calendar year of transplant. There were 157,201 person-years of observation among 17,468 recipients, with 82.2% of study time during graft function and 17.8% during dialysis after graft failure. There were 2003 deaths (12.7 deaths per 1000 person-years) overall, of which 985 occurred with graft function (7.6 deaths per 1000 person-years) and 1018 occurred during dialysis after graft failure (36.1 deaths per 1000 person-years). Each 1-year increment in calendar year of first transplant was associated with a significantly lower risk of death, both overall observation (HR 0.97 (0.96, 0.98)) and focusing on time with graft function (HR 0.98 (0.97, 0.99)). Living donation was significantly associated with better survival, whereas dialysis after graft failure was associated with a much higher mortality risk (HR 4.85 (4.40, 5.35)) compared with graft function. Thus, the risk of death with graft function has decreased in children receiving a first kidney transplant. Increasing living donation and minimizing dialysis may further improve outcomes.