Recovery Factors Affecting Utilization of Small Pediatric Donor Kidneys

Kidneys from small pediatric donors are underutilized. Using data from the Scientific Registry of Transplant Recipients for donors <21 kg in which at least one organ was recovered from 1997 to 2007 (n = 3341), donor and recovery factors were evaluated by multivariate analysis for associations with (a) kidney nonrecovery and (b) transplantation of recovered kidneys. Results: The proportion of kidney recoveries were 55% during liver procurements and 40% during intestine procurements amongst donors <10 kg (p < 0.01) compared to 93% and 88%, respectively, for donors weighing 10–20 kg (p = 0.003). Intestine procurement was independently associated with an 81% greater likelihood of kidney nonrecovery (p < 0.0001) and a 48% lower likelihood of transplantation (p = 0.0004). A multivariate Cox model indicated that single kidney recipients had a 63% higher risk of graft failure compared with en bloc kidney recipients (p < 0.0001); however, concurrent intestine recovery was not a significant risk factor for graft loss. Intestine recovery from donors <21 kg of age is strongly associated with higher kidney nonrecovery and lower transplantation rates. Graft survival is worse with single kidney transplantation, but is not significantly affected by intestine recovery. Small pediatric donors procurement teams should strive to increase kidney recoveries overall and en bloc recoveries in particular.     

Graft survival and graft function of pediatric en bloc kidneys in paraaortal position

BACKGROUND: En bloc kidneys from pediatric donors are regarded as questionable with respect to the safety and quality of the transplant outcome. Therefore, we retrospectively studied graft outcome and graft function of our 56 en bloc kidneys transplanted in paraaortal position between 1992 and 1999. METHODS: Graft outcome of en bloc kidneys (group A) was compared with graft outcome of single cadaveric adult donor kidneys (group B). Matched pairs were generated regarding HLA-missmatch, cold ischemic time, recipient age, body mass index, and systolic arterial blood pressure. RESULTS: Allograft survival rates of pediatric en bloc kidneys at 1, 3, and 5 years were significantly lower (group A: 78, 70, 70% vs. group B: 92, 92, 81%, P<0.05). Lower survival rate was caused by a higher number of graft losses in the early postoperative period (group A: 21% vs. group B: 4%, P<0.01) due to vascular complications. Main risk factor for graft loss was donor age of less than 12 months. Five years after transplantation serum creatinine of pediatric en bloc kidneys was significantly better than of adult kidneys (0.9+/-0.06 vs. 1.8+/-0.2 mg/dl, P<0.001). CONCLUSION: En bloc kidneys show a high percentage of graft survival with excellent long-term graft function. However, the early postoperative period carries a higher risk of graft loss in very young donors due to vascular complications. In the face of donor shortage en bloc kidneys from pediatric donors can successfully be transplanted in a paraaortal position.     

Single Kidney Transplantation from Young Pediatric Donors in the United States

Kidney transplantation (KTX) from small pediatric donors is performed as single or en bloc. Criteria to determine when to split pediatric donor kidneys and transplant as singles are not well established. Data reported to the Scientific Registry of Transplant Recipient for donors <10 yrs from 1995 to 2007 were reviewed (n = 5079). Donors were categorized by weight group by 5 kg increments and solitary (n = 3503) versus en bloc (n = 1576). The primary outcome was overall graft survival. Results were compared as adjusted hazard ratios (aHR) relative to ideal standard criteria donors (SCDs) (defined as age 18–39 without other risk factors), non‐ideal SCDs (all other SCDs) and expanded criteria donors (age 50–59 with other risk factors or age ≥60). Single KTX from donors ≥ 35 kg conferred a similar risk of graft survival as ideal SCDs. Of donors 10–34 kg, risks of en bloc KTX were similar to ideal and risks of single KTX to non‐ideal SCDs; single and en bloc KTXs had 7.9 and 5.2 graft losses per 100 follow‐up years, respectively. Single KTX from donors >35 kg are similar to ideal SCDs. Single KTX from donors 10–35 kg are similar to non‐ideal SCDs. From a resource perspective, pediatric donors 10–35 kg used as singles offer more cumulative graft years than when used en bloc.     

Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients

BACKGROUND: Transplantation of solitary pediatric renal allografts from donors 2 years of age or younger into adult recipients is controversial. METHODS: Between 1998 and 2001, 15 solitary renal allografts from pediatric donors 2 years of age or younger were transplanted into adult recipients. Thirty-three en bloc renal allografts transplanted between 1994 and 2001 were used for comparison. En bloc kidneys were considered for separation if they measured greater than or equal to 6 cm in length. Renal function (creatinine clearance [CrCl]) was estimated using the Cockroft-Gault formula. RESULTS: Two-year graft survival for the solitary and en bloc groups were 93% and 77%, respectively (P =0.405). Five grafts were lost because of arterial thrombosis (four en bloc and one solitary). Ureteral complications occurred in three grafts in the en bloc group. One-year postoperative CrCl of the surviving solitary (n=14) and en bloc (n=26) grafts were 51.4+/-26.2 mL/min and 55.1+/-27.5 mL/min (P >0.05), respectively. Donor weight and kidney length were greater in the solitary group (14.3+/-3.5 kg and 6.3+/-0.4 cm, respectively) compared with the en bloc group (10.8+/-2.6 kg and 5.9+/-0.3 cm, respectively) (P =0.001 and P <0.001). CONCLUSIONS: Separation of en bloc pairs into solitary allografts can be considered when the graft measures greater than or equal to 6 cm in length and donor weight is greater than or equal to 14 kg. The transplantation of solitary pediatric kidneys into adult recipients is successful, and the majority of pediatric en bloc allografts can be separated before transplantation.     

Hypothermic pulsatile perfusion and transplantation of pediatric cadaveric kidneys into adults.

Twenty-seven adults received en block or single renal allografts from pediatric donors less than 12 years of age. Hypothermic pulsatile perfusion of these small kidneys presented no technical difficulties. Flow rates ranged between 0.8-1.2 ml/min/gm. Single pediatric kidneys from donors as young as three years were able to produce a creatinine clearance of 50 ml/min in adults by one month posttransplant. No differences in renal function were noted between en bloc or single kidneys. En bloc transplants were associated with an increased incidence of renal arterial thromboses (3/8 cases). Because of this, pediatric cadaver kidneys were transplanted as single units, and an additional advantage was that they could provide donor kidneys for two recipients. In our series, one year pediatric graft survival is less than a comparable group of adult cadaveric kidney recipients.     

Outcome of renal transplants from pediatric donors <5 yr of age

AIM: Outcomes of single renal transplants from donors <5 yr old have traditionally been inferior to those from older donors. We retrospectively studied our experience with patients who received renal transplants, either individually or en bloc, from young donors (<5 yr of age) to determine the utility of these organs. We also compared the outcomes of these transplant patients maintained on either cyclosporine- (CyA) or tacrolimus-based (TRL) immunosuppression regimens. PATIENTS: Ninety-eight patients received transplants at our center from donors <5 yr of age between August 1993 and August 2003. They were followed-up from 12 months to 11 yr. Patients were divided into four groups based on whether they received single or en bloc transplants, and whether CyA or TRL was the base immunosuppressive agent. Patients in group I (n = 13) received single pediatric kidneys and were treated with CyA regimens; group II patients (n = 26) also received single pediatric kidneys, but were treated with TRL regimens; group III patients (n = 31) were transplanted en bloc and were treated with CyA; and group IV patients (n = 28) received en bloc transplants and were treated with TRL. RESULTS: One-year patient and death-censored graft survival was not significantly different between recipients of en bloc vs. single grafts (i.e. 88 and 85% vs. 90 and 87%, respectively), or between the four treatment groups (group I: 85 and 85%, group II: 92 and 88%, group III: 87 and 84%, and group IV: 89 and 86%, respectively). The overall 1-yr rejection rate was 30% (29 of 98), which was significantly higher in the CyA-treated patients 19 of 44; i.e. 43%, than in TRL-treated patients 10 of 54, i.e. 19%, p = 0.03). In the en bloc recipients, seven grafts (12%) were lost as a result of vascular thrombosis. Notably, none of the single kidneys were lost because of vascular thrombosis. At the end of follow-up the creatinine levels of both groups were comparable. CONCLUSIONS: Pediatric donor kidneys transplanted individually provide for equal patient and graft survival when compared with en bloc transplants. TRL can be used reduce the detrimental effect of acute rejection on graft growth and function when compared with CyA. Single use of such kidneys can safely and efficaciously be transplanted into adult recipients, greatly expanding the donor pool.     

Transplantation of kidneys from children

During an 11-year period from 1978 to 1988, 720 cadaver kidneys were transplanted at the University Hospital of Zurich. 103 of the kidney grafts were from donors 16 years old or younger. The mean age of these donors was 11 years (range 2 1/3 to 16 years). There were 3 donors under 5 years, where we preserved and transplanted both kidneys en bloc. Only 3 recipients were less than 16 years old. After 1 year, 67 out of 103 recipients had a functioning pediatric graft. In the cyclosporine-treated group, the 1-year graft survival was even 80%, similar to kidney transplants from adult donors. Graft loss was observed in 48 cases. 33 patients rejected the transplant and 10 grafts were lost after recurrence of the primary renal disease. Only 5 grafts had a vascular complication. We conclude that kidneys from pediatric donors can successfully be transplanted into adults.     

Long-term outcome of cadaveric pediatric en bloc transplantation--a 15-year experience

Pediatric en bloc transplantation of infant organs into adult recipients is a recognized technique to expand the number of kidneys available for transplantation. We reviewed our experience with this technique over a 15-year period to determine the long-term outcomes. Twelve patients underwent pediatric en bloc transplantation from donors aged <4 years. All transplants functioned immediately with no graft thrombosis. Two patients died 12 and 10 years posttransplant with functioning grafts. The remaining 10 recipients experienced excellent graft function with a mean follow-up time of 73.8 months (range, 10 to 169 months) with no evidence of hyperfiltration injury. We conclude that pediatric en bloc transplantations achieve excellent long-term allograft function in selected recipients.     

Pediatric En Bloc Dual Kidney-Pancreas Transplantation Into an Adult Recipient: a Simplified Technique. Benefits of the en bloc kidney-pancreas transplantation technique in pediatric donors

The lower age limit for pancreas donors is not well defined. Fear of inadequate islet beta-cell mass and of technical complications has hampered the use of pediatric donors. A surgical technique of 'en bloc' kidney-pancreas is described. Both kidneys and pancreas were removed en bloc from a 13-kg, 31-month-old child. During bench preparation, one anastomosis was performed between the portal vein and the inferior vena cava. The proximal end of the aorta was closed. The bloc was transplanted into a 36-year-old type I diabetic patient intraperitoneally in the right iliac fossa. The kidneys functioned immediately. Pancreatic graft function resumed after POD 15 but insulin therapy was maintained until POD 112. Currently, the patient retains excellent kidney and pancreas graft functions. Very young donors can be accepted as pancreas donors for adult recipients, although slow recovery of pancreatic function can be expected. Use of the en bloc technique is well suited for very small children, as it prevents potential vascular complications.     

Superiority of pediatric en bloc renal allografts over living donor kidneys: a long-term functional study

BACKGROUND: Growing waiting list for kidney transplantation in the United States makes it imperative to expand donor pool to use of pediatric kidneys. Because en bloc pediatric kidneys double nephron numbers, it would be interesting to learn how they fare compared to living donor kidneys long term. METHODS: Retrospective chart review was performed on all 72 pediatric en bloc and 75 live adult donor kidney recipients transplanted between January 1990 and December 2001. Long term graft function was assessed with glomerular filtration rate (GFR) using the abbreviated modification of diet in renal disease (MDRD) formula. RESULTS: Pediatric donor was 16.9 +/- 11.2 months old and weighed 10.7 +/- 3.8 kg. Nine en bloc kidneys thrombosed at a mean of 4.2 days posttransplantation. Proteinuria was detected later posttransplantation in en bloc group (45.6 +/- 33.6 months vs. 23.4 +/- 16.3 months, P = 0.002). Pediatric en bloc recipients had significantly higher GFR up to 8 years posttransplantation. One-year graft survival was significantly better in live donor group (93.3% vs. 81.9%, P = 0.041) but five-year graft survival rates were similar (86.7% vs. 76.3%, P = 0.125). One-year and five-year patient survival rates were similar between en bloc and live donor groups (97.3% vs. 98.6%, P = 0.585 and 94.6% vs. 93.0%, P = 0.688, respectively). CONCLUSION: Early postoperative graft thrombosis remain a challenge with pediatric en bloc renal transplants, but once the allografts survive early postoperative course, they provide better long-term function than living donor kidney transplants. In order to alleviate burden on waiting list, pediatric en bloc kidneys should be transplanted more often when available.     

Pediatric cadaver kidneys. Their use in renal transplantation.

Of 350 consecutive cadaver kidney transplants, 32 kidneys from donors aged 1 day to 9 years were transplanted. Our results indicate that, with strict adherence to certain guidelines in kidney procurement and transplantion, pediatric kidneys are excellent donor graft material. In contrast to en bloc transplantation of both kidneys from pediatric donors, each donor can provide kidneys for two recipients. In addition, the transplantation of pediatric kidneys as single units is both simple and safe.     

When is it reasonable to split pediatric en bloc kidneys for transplantation into two adults?

Background

Traditionally, kidneys from donors ≥60 years old and pediatric kidneys are considered marginal organs for transplantation. Pediatric donor kidneys are underutilized for transplantation into adult recipients due to concern for poor outcomes.

Methods

Using data from the Organ Procurement and Transplant Network, we analyzed patterns of pediatric kidney use (single vs en bloc) in the United States from 1987 to 2007. Using the Cox proportional hazards model, graft outcomes of pediatric donor kidneys transplanted as single vs en bloc grafts from different donor weight groups were compared with renal transplantation from donors ≥60 years old in an attempt to define a pediatric donor weight at which kidneys can be justifiably split to expand the donor pool.

Results

Compared with older donor kidneys, graft failure risk of pediatric single kidneys was consistently lower when the donor weight exceeded 10 kg. On the other hand, graft survival benefit for pediatric en bloc kidneys was evident starting at donor weight ≤10 kg in comparison to older donor kidneys. Pediatric en bloc kidneys performed consistently better than pediatric single kidneys for all donor weight groups.

Conclusions

Splitting of pediatric donor en bloc kidneys for transplantation into 2 adults when the donor weight exceeds 10 kg was associated with acceptable graft outcomes. This practice, along with increased use of small pediatric donor kidneys, may help to alleviate the waiting list burden in renal transplantation.     

En Bloc Transplantation of Kidneys from Pediatric Donors

PurposeCadaveric kidneys from pediatric donors represent an important resource for human allotransplantation. We report 7 cases in which a new technique was used for en bloc transplantation of pediatric cadaver kidneys into adult recipients.Materials and MethodsPaired cadaveric kidneys obtained from donors younger than 6 years (mean age 26 months) were transplanted en bloc into 2 children (mean age 12.5 years) and 5 adults (mean age 50 years) using en bloc extraperitoneal interposition of the donor aorta and vena cava into the recipient external iliac artery and vein.ResultsAll patients had excellent perfusion immediately following transplantation on^99m technetium-pentetic acid perfusion scans. Serum creatinine decreased to its nadir an average of 7 days post-transplantation in all but 1 patient. In 3 patients glomerular filtration rate increased 3 to 5-fold at 3 months and 6 months after transplantation. No patient had venous or arterial thrombosis postoperatively and 2 had ureteral leaks. In 3 patients moderate to severe biopsy proved acute rejection episodes were successfully reversed by intensifying immunosuppressive treatment and recovery of allograft function was excellent following antirejection therapy. Grafts were lost due to chronic rejection at 10 years in 1 patient and noncompliance in 1. Currently 5 patients are well with normal serum creatinine values at 3 months to 1 year of followup.ConclusionsEn bloc transplantation of small pediatric kidneys using a new technique averts the complication of vascular thrombosis and provides adequate mass to achieve a normal level of renal function.     

Single versus en bloc kidney transplantation from pediatric donors less than or equal to 15 kg

BACKGROUND: Kidney transplantation from small pediatric donors is being performed with increased frequency as single (SK) or en bloc (EBK) kidneys. METHODS: Between 2002 and 2006, 19 EBK and 14 SK transplants from pediatric donors less than or equal to 15 kg were performed. SK arterial anastomoses were performed to the aortic patch (n=8), aortic conduit (n=1), or renal artery orifice (n=5). RESULTS: En bloc kidney donors were on average younger (12+/-10 vs. 24+/-8 months, respectively; P=0.0102) and weighed less (10+/-3 vs. 13+/-3, respectively; P=0.0184). There were no differences between the two groups in recipient age, race, body mass index, degree of sensitization, retransplantation, and cold ischemia time; however, EBK recipients were somewhat better matched at the human leukocyte antigen DR locus (P=0.0515). Delayed graft function was more frequent in the SK group (25% vs. 0%; P=0.0542). Acute rejection occurred in 21% of recipients in both groups. Glomerular filtration rates were significantly higher with EBK than SK at 12-months posttransplantation. At 1 year, graft survival for SK and EBK was 86% and 79%, respectively (P=1.000). Graft thrombosis occurred in 0% (0/9) of SK recipients in which an aortic cuff or conduit was used, 40% (2/5) of SK recipients without an aortic cuff, and 5% (1/19) of EBK recipients (P=0.03). CONCLUSION: Short-term outcomes of kidneys from small pediatric donors are satisfactory when transplanted as SKs or en bloc; however, the absence of an aortic patch in SK transplantation is a risk factor for early thrombosis.     

Increasing the donor pool using en bloc pediatric kidneys for transplant

OBJECTIVES: En bloc pediatric kidney transplants (EBPKT) are still a subject of controversy. The aim of this study was to determine whether acceptable long-term graft survival and function can be achieved in EBPKT compared with the transplant of single, cadaveric, adult donor kidneys. METHODS: A retrospective review was conducted of 66 recipients of en bloc kidneys from cadaveric pediatric donors and 434 patients who underwent transplantation with a single kidney from an adult donor between January 1990 and May 2002 at the authors' hospital. The recipients were well-matched demographically. Both transplant groups were analyzed for short- and long-term performance in terms of transplant outcome and quality of graft function. RESULTS: Overall death-censored actuarial graft survival rates at 1 and 5 years were 89.2% and 84.6% in the adult kidney transplants (AKT) and 83.3% and 81.1% in EBPKT, respectively (P=0.56). In the EBPKT group, graft function was improved over that observed in AKT. Vascular thrombosis was the most common cause of graft loss in EBPKT. Acute rejection occurred more frequently in AKT and Cox's regression analysis indicated that undergoing an AKT was a predictive factor for acute vascular rejection (adjusted risk ratio, 3.8; 95% confidence interval, 1.4-10.2; P=0.001). CONCLUSIONS: Overall graft survival was similar in both groups, vascular complications were the main cause of graft loss in EBPKT, and the EBPKT showed excellent long-term graft function and a low incidence of acute rejection.     

Long-term follow-up of pediatric en bloc renal transplantation

We reviewed the outcomes of pediatric en bloc renal transplantation at two Canadian centers in the cyclosporine era. Between 1984 and 2002, 16 patients received pediatric en bloc renal transplants. Mean recipient age and weight were 45 +/- 17 years and 72.2 +/- 14.4 kg, respectively. En bloc kidneys were procured from donors aged 2.1 +/- 0.8 years (range, 0.7 to 4.0), weighing an average of 14.3 +/- 2.0 kg (range, 12 to 17). All en bloc kidneys were successfully transplanted without thrombosis. All patients received calcineurin inhibitors and corticosteroids. Only three patients received antibody-based induction therapy. Rejection episodes occurring in seven grafts were all successfully treated. Mean follow-up was 3.7 years (range 0.4 to 15.0). Mean serum creatinine values at 3 months and 1 and 3 years were 138.8 +/- 54.5 micromol/L, 118.6 +/- 38.1 micromol/L, and 95.1 +/- 24.4 micromol/L, respectively. The mean creatinine value of five patients with at least 5 years follow-up was 96.8 +/- 12.3 micromol/L. Three-year graft and patient survival rates were 94%. Two deaths with functioning grafts occurred secondary to cardiac and infectious etiologies. None of the grafts were lost independent of death. We conclude that en bloc transplantation has excellent short- and long-term results. Improving graft function after 3 years represented by reduced serum creatinine suggests that these kidneys have excellent renal reserve and growth potential.     

En-Bloc Kidney Transplantation in the United States: An Analysis of United Network of Organ Sharing (UNOS) Data from 1987 to 2003

With increasing donor organ shortages, en-bloc kidney (EBK) transplantation is an alternative to utilize very young or very old donor age cadaver kidneys for transplantation. Several single-center series have reported excellent graft survival (GS). We sought to determine national level registry-based patterns for GS and determine adjusted hazard ratios (AHR) for graft loss after EBK versus single kidney (SK) cadaver transplants.
Data reported to UNOS from 1987 to 2003 were analyzed using PHREG (SAS version 8.1) statistical procedures. Proportional hazards models were constructed that included multiple donor, recipient and surgical variables.
Of the 2160 EBK transplants reported, 77% were from donors < 5 years of age. EBK transplants had superior GS to SK transplants, when donor age was restricted to < 5 years (AHR 0.708, p < 0.001). GS at 1, 3 and 5 years post-transplant was superior with EBK (85%, 76% and 71%) versus SK (81%, 68%, 63% and p < 0.001 at all time points). EBK transplants from very young donors were associated with a significantly lower rate of delayed graft function than SK transplants (17.9% versus 23.4%, p < 0.001).
National registry data suggest that EBK transplants present a viable option for transplantation of very young donor kidneys.     

Long-term results of en bloc transplantation of pediatric kidneys into adults using a vicryl mesh envelope technique

En bloc transplantation of pediatric kidneys into adults is a suitable measure to help correct the shortage of available kidneys. This practice, however, is not widespread because of the high incidence of vascular complications. Our institution has previously described a vicryl mesh technique for en bloc kidneys, with an attempt to reduce the incidence of vascular complications. The purpose of this study was to evaluate the long-term results of recipients with en bloc kidneys stabilized with this technique. The charts of 644 adult renal transplants performed between July 1987 and July 1999 were reviewed. During this period, 14 adult patients have received 14 pairs of en bloc pediatric kidneys using the vicryl mesh technique. All patients received OKT3 as an induction immunosuppression with cyclosporine started 10-14 d after the transplant. The median donor age was 24 months (range 14-84 months), and the median recipient age was 49 yr (range 23-68 yr). The mean recipient weight was 79 kg (range 60-114 kg). The mean cold ischemia time was 14.2 hr. None of the patients developed vascular or urological complications. Delayed graft function and moderate acute rejection occurred in one patient each. At a mean follow-up of 51 months (range 7-96 months), all 14 patients maintained excellent renal function with a mean creatinine of 1.01 mg/dL. Renal measurements pre-operatively and at follow-up ultrasound examinations were available in 9 patients, and the mean length of the kidneys had grown approximately 5.0 cm. These data demonstrate that minimal vascular and immunological complication rates can be achieved with pediatric en bloc kidneys using the vicryl mesh envelope technique.     

Transplantation of en bloc pediatric kidneys with a partial bladder segment in an adult recipient

The success of transplantation of the urinary bladder en bloc with pediatric kidneys remains undetermined. We transplanted a large portion of the bladder with en bloc kidney allografts from a 13-month-old donor into a 45-year-old adult male. The recipient, who was on long-term hemodialysis, had a small urinary bladder consistent with long-standing anuria. Informed consent was given and bilateral kidneys were transplanted en bloc with both ureters and bladder. The patient's bladder was augmented with the donor bladder and bilateral ureteroneocystotomies of small ureters was avoided. At 3 and 18 months post-transplantation, cystoscopies revealed a viable bladder with new vessels and normal donor bladder. Cystogram revealed no reflux. The bladder segment was reperfused via blood supply from both ureters and then from the recipient's bladder. It seems that bladder transplantation en bloc with pediatric kidneys is a viable option for augmentation of a small recipient bladder that allows avoidance of very small bilateral ureteroneocystotomies.     

Influence of Graft Type on Outcomes After Pediatric Liver Transplantation

We sought to determine which type of donor graft provides children and young adults with the best outcomes following liver transplantation. Using the US Scientific Registry of Transplant Recipients database, we identified 6467 recipients of first liver transplants during 1989-2000 aged < 30 years. We used Cox models to examine adjusted patient and graft outcomes by age (< 2, 2-10, 11-16, 17-29) and donor graft type (deceased donor full size (DD-F), split (DD-S), living donor (LD)]. For patients aged < 2, LD grafts had a significantly lower risk of graft failure than DD-S (RR = 0.49, p < 0.0001) and DD-F (RR = 0.70, p = 0.02) and lower mortality risk than DD-S (RR = 0.71, p = 0.08) during the first year post-transplant. In contrast, older children exhibited a higher risk of graft loss and a trend toward higher mortality associated with LD transplants. In young adults, DD-S transplants were associated with poor outcomes. Three-year follow up yielded similar graft survival results but no significant differences in mortality risk by graft type within age group. For recipients aged < 2, LD transplants provide superior graft survival than DD-F or DD-S and trend toward better patient survival than DD-S. Living donor is the preferred donor source in the most common pediatric age group (< 2 years) undergoing liver transplantation.