title: Practice patterns and outcomes in retransplantation among pediatric kidney transplant recipients.
abstract: BACKGROUND
  More than 25% of pediatric kidney transplants are lost within 7 years, necessitating dialysis or retransplantation. Retransplantation practices and the outcomes of repeat transplantations, particularly among those with early graft loss, are not clear.
  
  
  METHODS
  We examined retransplantation practice patterns and outcomes in 14,799 pediatric (ages <18 years) patients between 1987 and 2010. Death-censored graft survival was analyzed using extended Cox models and retransplantation using competing risks regression.
  
  
  RESULTS
  After the first graft failure, 50.4% underwent retransplantation and 12.1% died within 5 years; after the second graft failure, 36.1% underwent retransplantation and 15.4% died within 5 years. Prior preemptive transplantation and graft loss after 5 years were associated with increased rates of retransplantation. Graft loss before 5 years, older age, non-Caucasian race, public insurance, and increased panel-reactive antibody were associated with decreased rates of retransplantation. First transplants had lower risk of graft loss compared with second (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.64-0.80; P<0.001), third (aHR, 0.62; 95% CI, 0.49-0.78; P<0.001), and fourth (aHR, 0.44; 95% CI, 0.24-0.78; P=0.005) transplants. However, among patients receiving two or more transplants (conditioned on having lost a first transplant), second graft median survival was 8.5 years despite a median survival of 4.5 years for the first transplant. Among patients receiving three or more transplants, third graft median survival was 7.7 years despite median survivals of 2.1 and 3.1 years for the first and second transplants.
  
  
  CONCLUSIONS
  Among pediatric kidney transplant recipients who experience graft loss, racial and socioeconomic disparities exist with regard to retransplantation, and excellent graft survival can be achieved with retransplantation despite poor survival of previous grafts.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Van Arendonk
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Garonzik Wang
authors.forename: Neha A
authors.initials: NA
authors.lastname: Deshpande
authors.forename: Nathan T
authors.initials: NT
authors.lastname: James
authors.forename: Jodi M
authors.initials: JM
authors.lastname: Smith
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Paul M
authors.initials: PM
authors.lastname: Colombani
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D016030:Kidney Transplantation / Q000208:ethnology / Q000401:mortality* / Q000706:statistics & numerical data*; D008297:Male; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000639:trends*; D044469:Racial Groups; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D015996:Survival Rate; D013997:Time Factors; D014180:Transplantation; D016896:Treatment Outcome; D055815:Young Adult
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