Background: Pediatric kidney transplant supply far outpaces demand. One approach to this problem is to expand donor criteria without compromising recipient outcomes. Live-related donors (LRD) are known to offer superior outcomes compared to deceased donors (DD) but outcomes in suboptimal LRDs have not been studied.
Methods: In this retrospective review of primary kidney recipients <18 years in the United Network for Organ Sharing database that received ABO matched donor kidneys on or after 2010, 10-year graft survival of perfect DD recipients was compared to suboptimal LRD recipients with unfavorable risks like diabetes history, hypertension (treated with medication), smoking history (≥10 pack-years), BMI (≥30), HLA mismatch (≥3), creatinine (≥1.5mg/dL) and age (≥50 years).  Graft survival was compared using the log-rank test and depicted graphically with a Kaplan-Meier curve.
Results: Perfect DDs comprised 2.9% (n=175) of DD (N=6,060), while suboptimal LRDs with 1 and 2-criteria made up 68% (n=1,575) and19.6% (n=455) of the overall LRD (N=2,315) respectively. 
 
Perfect DDs had a mean 10-year graft survival of 0.725 (95% CI: 0.659 - 0.791). For overall LRD, with 1-criteria and with 2-criteria, the 10-year graft survival were 0.805 (0.789 - 0.821), 0.797 (0.777 - 0.816), and 0.746 (0.706 - 0.786), respectively. LRD groups had significantly superior graft survival compared to all DD groups, while perfect DD trended toward higher graft survival but was not superior to all DD groups [0.628 (0.616 - 0.640)] (p = 0.1680).
 
All the LRD groups achieved better, though not statistically significant, graft survival than perfect DD (p>0.05).
Conclusion: This preliminary analysis suggests that significant unfavourable criteria may be tolerated in LRD. Perfect DDs represent the most ideal scenario for a DD, with suboptimal LRD’s still achieving noninferior outcomes despite multiple unfavourable criteria. These data support a re-evaluation of donor selection and allocation policies to account for the tangible benefits—such as shortened wait times and better long-term outcomes—conferred by suboptimal live donation. Future prospective studies and risk stratification models will further refine donor selection criteria to improve the care of pediatric transplant recipients.