Children and teens with chronic kidney disease (CKD) who spend extended time with severely reduced kidney function are substantially more likely to receive kidney transplants, especially living donor transplants that avoid dialysis altogether. A new analysis of over 300 young patients reveals that each additional year spent with low kidney function increases the odds of receiving a preemptive transplant (one before dialysis becomes necessary) by 45%.

The finding underscores a critical gap in how pediatric kidney disease is managed: many young patients are not referred for transplant evaluation early enough, missing a crucial window to identify living donors and prepare for surgery before their kidneys fail completely.

What Does Low Kidney Function Mean for Young Patients?

Kidney function is measured using a metric called estimated glomerular filtration rate (eGFR), which reflects how well the kidneys filter waste from the blood. When eGFR drops to between 10 and 30 milliliters per minute per 1.73 square meters of body surface area, it signals advanced kidney disease and the need for urgent transplant planning.

In the study of 333 children and teens with CKD, the median time spent at this critically low eGFR level was about 29 months. Researchers found that youth who had more time in this window were significantly more likely to receive a preemptive transplant, meaning they avoided dialysis entirely. Overall, 45% of the young patients in the study received preemptive transplants, while 77% were waitlisted before needing dialysis.

However, access to transplant was not equal across racial and ethnic groups. White children received preemptive transplants at a rate of 56%, compared to just 24% of Black children. Notably, Black patients spent an average of 6.5 fewer months with low eGFR, suggesting they may have experienced faster kidney disease progression or were referred later in their disease course.

Why Does Time Matter for Transplant Success?

The relationship between time and transplant access reveals something important about the transplant process itself: it takes time to find a living donor, complete medical evaluations, and prepare for surgery. Simply being on a transplant waitlist is not enough. The study found that each additional year with low eGFR increased the likelihood of receiving a living donor transplant by 42%, but did not increase the likelihood of being waitlisted in the first place.

This distinction matters because living donor transplants offer better outcomes than deceased donor transplants. They typically function longer and allow patients to avoid dialysis entirely, which improves both quality of life and long-term survival.

"To avoid dialysis and identify a living donor, a child must be referred for transplant early to allow time for planning and living donor evaluation," explained Sandra Amaral, MD, associate professor of pediatrics and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, who led the study.

Sandra Amaral, MD, Associate Professor of Pediatrics and Epidemiology, University of Pennsylvania

How to Improve Early Transplant Referral for Young Kidney Patients

• Establish Clear Referral Thresholds: Nephrologists should refer children for transplant evaluation when eGFR reaches 30 mL/min/1.73 m2 or higher, rather than waiting until kidney function declines further, to maximize time for donor identification and surgical planning.
• Prioritize Black and Hispanic Youth: Special attention is needed to ensure early referral for children from racial and ethnic groups that historically receive fewer living donor transplants and may experience faster CKD progression.
• Begin Living Donor Discussions Early: Transplant centers should initiate conversations about living donation as soon as advanced CKD is diagnosed, allowing families adequate time to identify potential donors and complete the evaluation process.
• Address Systemic Barriers: Healthcare systems must investigate and remove obstacles to transplant access, including financial constraints, transportation challenges, and donor eligibility issues that may disproportionately affect certain communities.

The study, published in Pediatric Nephrology, was supported by the National Institutes of Health and included 333 children and teens with CKD, of whom 160 were White, 72 were Black, 65 were Hispanic, and 36 were from other ethnic backgrounds.

What Are the Barriers to Timely Transplantation?

Despite the clear benefits of early referral, significant gaps remain. Only about 25% of children with CKD receive living donor transplants, and fewer than half avoid dialysis before transplant. Researchers identified several potential barriers that were not fully captured in this study, including family-level obstacles such as financial hardship and transportation difficulties, as well as donor eligibility issues.

"Earlier transplant referral is critical, as each additional year with low eGFR substantially increased odds of preemptive transplantation. Because preemptive transplants were largely driven by living donation, efforts to identify potential donors should begin as early as possible," noted Marissa Lipton, MD, clinical assistant professor of pediatrics and a pediatric nephrologist at Hassenfeld Children's Hospital at NYU Langone Health.

Marissa Lipton, MD, Clinical Assistant Professor of Pediatrics, NYU Langone Health

The findings highlight an important reality: waitlisting alone is insufficient to ensure timely transplant in pediatric CKD. The process of finding a living donor, completing medical evaluations, and preparing for surgery requires months of advance planning. Without early referral, young patients may miss the opportunity to receive a living donor transplant and instead face years on dialysis, which carries higher risks of infection, cardiovascular complications, and reduced quality of life.

Moving forward, additional research is needed to define the optimal timing for transplant referral and to better understand the specific barriers that prevent Black and Hispanic youth from accessing living donor transplants at the same rates as White youth. By addressing these disparities and ensuring early referral becomes standard practice, nephrology providers can help more young patients avoid dialysis and achieve the better long-term outcomes that transplantation offers.