Purpose of review: Advances in technology to assess immunologic risk in solid organ transplant offer an opportunity to optimize the approach to pediatric deceased donor kidney transplant in the setting of a new allocation system in the United States.
Recent findings: Degree of human leukocyte antigen (HLA) mismatch, class II HLA mismatch, unacceptable antigens and donor-specific antibody (DSA) detected by solid-phase assays, and epitope matching pretransplant affect pediatric kidney transplant outcomes. Detection of de novo DSAs (dnDSAs) posttransplant has been associated with increased risk of acute rejection and worse allograft function. Development of dnDSA occurs in recipients with greater epitope mismatching.
Summary: Improved long-term outcomes may be anticipated in pediatric kidney transplant recipients by incorporating extended HLA mismatch information and updating the clinical approach to donor kidney matching using available technology to identify clinically relevant immunologic risk.