Introduction: Potential pediatric kidney transplant recipients (KTRs) are evaluated for kidney transplantation (KTx) based on specific criteria such as HLA immunology. Although there are no established guidelines for accepting donor kidneys. A previous survey highlighted the varying perspectives of clinicians regarding kidney offer acceptance. This study aimed to investigate the factors influencing the acceptance of kidneys offered to pediatric KTRs.
Methods: Based on a previously conducted survey, a vignette-case-based survey was designed consisting of fictitious vignette cases of potential kidney offers. The following 7 factors with 2 distinct levels each were combined generating a total of 128 (27) vignette cases: (I) mismatches (MM) on HLA A, B, C (≤3/≥4); (II) MM on HLA DR, DQ (≤2/≥3); (III) donor eGFR (≥50/<50 ml/min/1.73m²); (IV) donor age (≤1/2-50 years); (V) recipient age (<2/≥2 years); (VI) recipient status (preemptive/dialysis); (VII) donor history of sepsis or bacterial infection (yes/no). Vignettes were partitioned into 8 vignette sets with 16 vignettes each. Pediatric nephrologists involved in pediatric KTx were asked to participate via the mailing lists of international (ESPN, ERKNet, IPTA) and the German associations for pediatric nephrology/Tx. One of 8 vignette sets was assigned randomly to each participant, who decided on the kidney offer for each vignette. Univariate and multivariate logistic regression with random intercept were used to analyse the impact of the 7 factors on the decision-making.
Results: Between December 2024 and February 2025, a total of 533 vignette were answered by 40 participants, of which 31 responded completely and 9 partially to the assigned vignette set, resulting in 3-5 responses per vignette. Participants had over 10 years of experience in pediatric KTx in most cases (60%) and came from 12 different allocation organisations in Europe, Iran and Canada, most commonly Eurotransplant (58%). Experience (p=0.15) or gender (p=0.68) did not influence the acceptance of a kidney. There was significant impact on the acceptance of a donor kidney for 4/7 vignette factors in the multivariate logistic regression including vignette set and factors as independent variables. If HLA MM on A, B, C was ≥4 (p=0.0110), or HLA MM on DR, DQ ≥3 (p<0.0001), donor eGFR <50 ml/min/1.73m² (p<0.0001), or donor age ≤1 year (p=0.0034), a kidney offer was significantly more likely to be declined. Recipient age, donor with/without sepsis or bacterial infection, or a recipient on dialysis/preemptive KTx, had no significant influence the acceptance of a kidney offer.
Conclusion: This international multicentre survey highlights that factors, such as HLA mismatches on DR, DQ and donor eGFR, have a significant impact on the complex decision-making process of a pediatric kidney offer. Our findings suggest that there is room for further research into explicit donor acceptance guidelines.