The transition from pediatric to adult health care is a vulnerable time for patients with chronic
conditions. We need to better understand the factors affecting the health of kidney transplant
recipients during this transition.
To determine the age at which renal transplant recipients are at greatest risk for graft
Design, Setting, and Participants
We performed a retrospective analysis of 168 809 first kidney-only transplant events from
October 1987 through October 2010, in recipients up to age 55 years as reported by the Organ
Procurement Transplantation Network Standard Transplant Analysis and Research Database. Recipient
age at transplant was the primary predictor studied. Confounder and effect modifier covariates were
identified and studied using Cox proportional hazard models.
Main Outcomes and Measures
Patient and renal graft survival, along with death-censored and non–death-censored
A total of 168 809 renal transplant events met the inclusion criteria. Recipients who
received their first kidney transplant at age 14 to 16 years were at the highest risk of graft loss,
with inferior outcomes starting at 1 and amplifying at 3, 5, and 10 years after transplant. Black
adolescents were at disproportionately high risk of graft failure. The variables that had
significant interaction with recipient age were donor type (deceased vs living) and insurance type
(government vs private). Among 14-year-old recipients, the risk of death was 175% greater in the
deceased donor–government insurance group vs the living donor–private insurance group
(hazard ratio, 0.92 [95% CI, 0.90-0.94] vs 0.34 [95% CI, 0.33-0.36]), whereas patient survival rates
in the living donor–government insurance and deceased donor–private insurance groups
were nearly identical (hazard ratio, 0.61 [95% CI, 0.58-0.63] vs 0.54 [95% CI, 0.51-0.56]).
Conclusions and Relevance
Recipients aged 14 to 16 years have the greatest risk of kidney allograft failure. Black
adolescents and those with government insurance are at even higher risk. Private insurance reduces
risk of death across all ages. Comprehensive programs are needed for adolescents, especially for
those at greater risk, to reduce graft loss during the transition from adolescence to adulthood.