Second kidney transplant during childhood: clinical aspects, outcomes, and risk factors for graft survival

Background The demand for kidney retransplants in the pediatric population is increasing as children are receiving their first transplants at a younger age. Methods This retrospective study included 51 children who underwent a second transplantation during childhood. We compared demographic and transplant characteristics, together with the clinical approach at the first and second transplants. Outcomes of second transplants were reported, and factors influencing repeat graft survival were investigated. Results Most of the children were male (69%), with congenital anomalies of the kidney and urinary tract as the primary cause of kidney failure (57%). Fifteen children (39%) weighing 20 kg or less underwent a second transplant. The leading cause of first graft loss was non-immunological (55%), being 27% vascular thrombosis. For the second transplantation, thymoglobulin, tacrolimus, and mycophenolate were preferred, with more frequent indications for anticoagulation prophylaxis. This approach was tailored to a significantly different clinical scenario: only 12% were susceptible to viral infections, and 59% were sensitized (PRA > 50%). After the second transplant, the patient survival rate was 100%, and the second allograft survival rates were 88% and 83% at 1 and 3 years, while after the first transplant, they were 94% and 91%, respectively. The proportional hazard model did not reveal any significant factors influencing the outcomes. Conclusions The clinical and immunological characteristics of children differed significantly between their first and second transplants, necessitating distinct medical approaches. Despite these challenges, pediatric kidney retransplantation seems to have a unique narrative and shows favorable outcomes, with high patient and graft survival rates, representing an effective treatment option.