Kidney transplantation (KT) is the treatment of choice for end-stage renal disease. Pre-emptive KT is considered to be the most optimal treatment of ESRD particularly in children but reports on the results of paediatric pre-emptive KT are scarce. The objective of this study was to evaluate the impact of pre-emptive KT on the risk of graft failure in children with ESRD.

We analyzed all first kidney transplants performed in children <19 years in France between 1994 and 2012. A Cox multivariable model with competing risk analysis was used to study the impact of pre-emptive KT on the hazard of graft failure defined as return to dialysis, re-transplant, or death, whichever occurred first.

A total of 1920 paediatric patients were included, of whom 387 (20.2%) received a pre-emptive KT. Median time of follow-up was 7.0 years [IQR (3.0–11.7)]. At 10 years post-transplant, graft survival was 85.2% in pre-emptive KT and 67.1% in non-pre-emptive KT (P<0.001). After adjustment for recipient age and sex, primary kidney disease, donor type (living or deceased donor), donor age, HLA mismatches, and cold ischemia time, and year of KT, pre-emptive KT was associated with a 45% reduction in the hazard of graft failure when compared with dialysis prior to KT (HR 0.55; 95%CI 0.41–0.73; P<0.001). Patient survival was not significantly influenced by pre-emptive KT. The impact of pre-emptive KT on graft failure risk was greater among deceased donor transplant recipients (HR 0.52; 95%CI 0.37–0.72) than in living donor kidney recipients (HR 0.67; 95%CI 0.31–1.25). Pre-transplant dialysis was associated with an increased hazard of graft failure, whatever the duration of dialysis.

In France, pre-emptive KT in children is associated with a lower risk of graft failure than KT performed after the initiation of dialysis, and should be encouraged when feasible.