Renal Transplantation From Pediatric Donors in the United Kingdom Rajiv V. Dave, 1 Abdul R. Hakeem, 1 Michael J. Dawrant, 1 Clare L. Ecuyer, 1 Andrew J.P. Lewington, 2 Magdy S. Attia, 1 Lutz Hostert, 1 Eric Finlay, 3 and Niaz Ahmad 1 Background. Significant disparity exists in the United Kingdom between the need for organ transplant and supply of deceased donor organs. In the recent years, efforts to increase donation has improved the rate of mainly deceased donors after circulatory death and from older donors. The rate of donation from pediatric population has remained low and those younger than 2 years including neonatal donation has remained largely unexplored. Methods. A retrospective review of the outcome of renal transplantation from pediatric donor (<18 years) kidneys in the United Kingdom. Results. Our results show a poor referral and conversion rate, and high discard rate (43%) of kidneys procured from donors younger than 2 years. During the 15-year study period (1997–2011), 47 donors younger than 2 years were referred (3 per year). Of these, 26 proceeded to donation resulting in 17 transplants (65% utilization). The referral rate for donors 2 years or older to younger than 5 years also remains low (76 in 15 years), but the conversion (88%) and utilization rates (73%) are better in this group. There was better utilization in donors aged 5 years or older to younger than 18 years. Overall graft and patient survival remains excellent in all 3 groups; with comparable survival of 82%, 85%, and 77% (P = 0.29) with mean follow-up periods of 9, 12.5, and 11.8 years, respectively. Conclusions. Despite excellent outcome, the referral, donation, and utilization of kidneys from donors younger than 5 years and particularly those younger than 2 years remain low. We suggest implementing improved strategies to increase donation from this group of population. (Transplantation 2015;99: 1968–1975) T he availability of donor organs continues to be a rate- limiting factor for renal transplantation. Despite re- cent improvement in the rate of donation 1 approximately 2 in 3 patients on the transplant waiting list in the United Kingdom will not receive an offer of a deceased donor kidney. During the last decade, we have seen an expansion in living kidney donor transplantation, which has reached a plateau (1000 transplants a year) for the last 4 years. The national directive of increasing deceased donation by 50% in 5 years has achieved its target of donation but not with a similar increase in transplant rate and at a cost of increased rate of discard of kidneys and other organs. 1 Most of the recent expansion in donation has happened in the area of donation after circulatory death (DCD) and donors at the older extreme of age. To expand the donor pool further more, extended criteria donors (ECD) are being used. The combination of ECD and DCD donor characteristics are expected to yield less than optimal outcome. In 2012, 34% of deceased kidney donors were over the age of 60 years. Over 50% of these donors were DCD. In 2001, only 15% of donors were over the age of 60 years, and most (95%) were DBD donors. 2 This paradigm shift reflects a severe imbalance between the demand and supply of deceased donor kidneys. It has been well established that using ECD kidneys although well justifiable when compared to the risk on the waiting list, the risk of recipient mortality and premature graft loss is higher compared to standard criteria kidneys. 3 Some centers use innovative strategies to assess, allocate, and improve outcome from such kidneys, including hypothermic machine perfusion, normothermic perfusion and conditioning, transplant with virtual cross-match (to reduce cold ischemia time), and dual transplantation (to provide sufficient nephron mass). Although much of the donor expansion has happened at the older age of the spectrum, donors at the other end of the spectrum remains relatively unexplored in the United Kingdom. This is particularly true for donors younger than 2 years. There may be multiple factors explaining this relative gap in the entire pathway from referral to utilization, there is lack of consensus and perhaps a degree of reluctance among Received 23 May 2014. Revision requested 29 October 2014. Accepted 29 October 2014. 1 Division of Surgery, Department of Transplantation, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom. 2 Department of Nephrology, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom. 3 Department of Paediatric Nephrology, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom. The authors declare no funding or conflicts of interest. N.A. conceptualized the study and obtained the national dataset. R.D. performed detailed statistical analysis and wrote the article. C.E. helped in gathering the missing data. N.A., A.H., M.D., A.L., M.A., L.H., and E.F. reviewed and edited the article. N.A. approved the final version. Correspondence: Niaz Ahmad, MBBS, MD, FRCS, Consultant Surgeon Division of Surgery, Department of Transplantation St James’s University Hospital Beckett Street Leeds LS9 7TF, United Kingdom. (niaz.ahmad@leedsth.nhs.uk) Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9909-1968 DOI: 10.1097/TP.0000000000000575 Original Clinical ScienceçGeneral 1968 www.transplantjournal.com Transplantation ■ September 2015 ■ Volume 99 ■ Number 9 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.