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Renal retransplantation of children: Is a policy ‘first cadaver donor, then live donor’ an acceptable option?

Abstract: Retransplantation is often a necessity for children with end‐stage renal disease (ESRD), as kidney graft survival is still not infinite. If a suitable live donor is present, the current policy is to use the live donor first, in order to obtain excellent long‐term outcome and to prevent human leucocyte antigen (HLA) sensitization. Data from the Eurotransplant International Foundation were analyzed to determine whether the sequence, first a cadaveric donor then a live donor, is acceptable. Between January 1 1983 and December 31 1995, 1305 children received a first renal transplant; 269 of them had a second transplant during the same period. Follow‐up of at least 1 yr was available. Categories were made according to the sequence of renal donor source: 217 patients were classified as first cadaver and second cadaver (1cad‐2cad) transplant, 26 as first cadaver and second live (1cad‐2liv) donor transplant, 23 as first live donor and second cadaver (1liv‐2cad) transplant and three patients had two subsequent live donor transplants (1liv‐2liv). When a live donor transplant was carried out, either first or second, the donor age was always higher, and the chance of a pre‐emptive transplantation or short stay on dialysis was higher, compared with a cadaver transplant. The re‐graft survival rate of the ‘1cad‐2liv’ was better than the ‘1cad‐2cad’ and ‘1liv‐2cad’ transplants. At 5 yr, the survival was 76%, 49%, and 61%, respectively. These data suggest that, when a suitable live donor is not available for a first transplantation owing to medical and/or familial reservations, a policy of ‘first a cadaver donor then a live donor’ transplantation is a viable option and should even be promoted. The pre‐emptive stage of the second transplant, probably with a live donor, is additionally advantageous.