Pediatric kidney transplantation using donors after circulatory death: a national experience from Spain

BACKGROUND: The shortage of pediatric kidney donors has increased interest in donation after circulatory death (DCD) as an alternative for transplantation. METHODS: This multicenter, retrospective study analyzed all pediatric kidney transplants (KT) from DCD donors performed in Spain between 2013 and 2024 in recipients under 18 years and compared them with 490 KTs from donation after brain death (DBD) donors during the same period. RESULTS: Sixty-four DCD KTs were included. Delayed graft function (DGF) occurred in 12% of cases. DGF risk was higher with donor age > 40 years (p > 0.05) and in grafts retrieved using the rapid recovery (RR) extraction technique (p < 0.05). The median functional warm ischemia time was 13 min (IQR:9-18) and was not associated with an increased risk of DGF. The median cold ischemia time (CIT) was 12.8 h (IQR:9.4-17), and longer CIT was associated with a nonsignificant increase in DGF risk. No DGF occurred when CIT was < 14 h and no additional risk factors were present. Recipients with DGF had a lower estimated glomerular filtration rate one month post-transplant (p < 0.05), but no significant difference at one year. Five-year graft survival rates were not significantly lower in DCD compared to DBD KTs (89.7% vs. 88.5%). CONCLUSIONS: Although DGF risk was associated with older donor age, RR technique, and longer ischemia times, it did not affect one-year graft function. Graft survival with DCD donors did not appear inferior to that with DBD. DCD KT appears feasible in pediatric recipients and may help expand donor availability under carefully selected conditions.