Importance: The transition from pediatric to adult health care is a vulnerable time for patients with chronic conditions. We need to better understand the factors affecting the health of kidney transplant recipients during this transition.
Objective: To determine the age at which renal transplant recipients are at greatest risk for graft loss.
Design, setting, and participants: We performed a retrospective analysis of 168,809 first kidney-only transplant events from October 1987 through October 2010, in recipients up to age 55 years as reported by the Organ Procurement Transplantation Network Standard Transplant Analysis and Research Database. Recipient age at transplant was the primary predictor studied. Confounder and effect modifier covariates were identified and studied using Cox proportional hazard models.
Exposure: Kidney-only transplant.
Main outcomes and measures: Patient and renal graft survival, along with death-censored and non–death-censored information.
Results: A total of 168,809 renal transplant events met the inclusion criteria. Recipients who received their first kidney transplant at age 14 to 16 years were at the highest risk of graft loss, with inferior outcomes starting at 1 and amplifying at 3, 5, and 10 years after transplant. Black adolescents were at disproportionately high risk of graft failure. The variables that had significant interaction with recipient age were donor type (deceased vs living) and insurance type (government vs private). Among 14-year-old recipients, the risk of death was 175% greater in the deceased donor–government insurance group vs the living donor–private insurance group (hazard ratio, 0.92 [95% CI, 0.90-0.94] vs 0.34 [95% CI, 0.33-0.36]), whereas patient survival rates in the living donor–government insurance and deceased donor–private insurance groups were nearly identical (hazard ratio, 0.61 [95% CI, 0.58-0.63] vs 0.54 [95% CI, 0.51-0.56]).
Conclusions and relevance: Recipients aged 14 to 16 years have the greatest risk of kidney allograft failure. Black adolescents and those with government insurance are at even higher risk. Private insurance reduces risk of death across all ages. Comprehensive programs are needed for adolescents, especially for those at greater risk, to reduce graft loss during the transition from adolescence to adulthood.