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Pediatric Renal Transplantation in India – A Single Center Experience
, Raja Lakshmanan1, Pranov Rengaswami1, Charankumar Swamikkannu1, Suprajaa VS1, Manojkumar V1,, Methun Senthur1, Dineshkumar Thanigachalam1, Sakthirajan Ramanathan1, Sheik S Alavudeen1, Seenivasan Mookaiah1, Jayalakshmi Seshadri1, Balasubramanian Thoppalan1, Gopalakrishnan Natarajan2
Corresponding author: Aravindhmozhi P, Department of Nephrology, Madras Medical College, Chennai, India. E-mail: mozhiaravindh@gmail.com
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Received: ,
Accepted: ,
Abstract
Background
Renal transplantation is the treatment of choice for children with end-stage renal disease, offering better growth, development, and quality of life when compared to dialysis, but long-term data from India are limited.
Materials and Methods
We retrospectively reviewed 53 pediatric recipients (<18 years) who underwent kidney transplantation at a South Indian tertiary center between January 2005–2025. Demographics, donor characteristics, immunosuppression, complications, rejection, infections, and survival were analyzed. Survival was estimated by Kaplan-Meier methods.
Results
The mean age at transplant was 14.9 ± 2.7 years; 62.3% were male. Live-related donor transplants comprised 94.3%. Etiologies included primary glomerular diseases (37.7%) and congenital anomalies of the kidney and urinary tract (26.4%). Anti-thymocyte globulin was the most common induction agent (41.5%), and tacrolimus-based regimens were used in 64.2%. Delayed graft function occurred in 15.1%. Acute rejection was documented in 34%, Antibody-mediated rejection (ABMR) in 60%, T-cell-mediated rejection (TCMR) in 32%, and combined ABMR and TCMR in 8%. Infections occurred in 58.5%, mainly urinary tract and respiratory infections. Graft survival rates at 1, 5, and 10 years were 96.2, 75, and 56%, respectively; patient survival at last follow-up was 73.6%.
Conclusion
Early graft survival in our setting is comparable to the other series. Long-term outcomes are impacted by infectious complications and chronic rejection.
Keywords
End stage renal disease
Graft survival
Paediatric population
Rejection
Renal transplantation
Introduction
Renal transplantation is the preferred modality of renal replacement therapy for children with end-stage renal disease (ESRD), offering better growth, neurocognitive development, and quality of life when compared to dialysis.1 In India, pediatric transplantation is challenged by late referrals, high infection burden, and resource constraints, yet encouraging results have been reported from several centers.2-5 However, data regarding pediatric renal transplantation is relatively sparse in India. This study aims to evaluate the demographic profile, immunosuppressive protocols, complications, and long-term outcomes of pediatric renal transplant recipients at our tertiary care center over a 20-year period, to highlight the real-world results achievable in a public-sector setting, and to identify challenges that remain unique to resource-limited environments.
Materials and Methods
This retrospective observational study was conducted at the Department of Nephrology, Rajiv Gandhi Government General Hospital, Chennai, a tertiary care referral center in South India. The study period spanned from January 2005–2025. All 53 pediatric patients (<18 years) who underwent renal transplantation during the study period were included.
Medical records were reviewed for demographic characteristics, donor and recipient details, induction and maintenance immunosuppression, surgical parameters, perioperative outcomes, rejection episodes, infection profile, graft function, and survival status. Follow-up duration was calculated from the date of transplantation to the last documented visit or death.
Definitions
Delayed graft function (DGF): Requirement for dialysis within the first week post-transplant. Acute rejection: Classified according to the Banff criteria on allograft biopsy. Graft survival: Time from transplantation to irreversible graft failure (return to dialysis or retransplant). Patient survival: Time from transplantation to death from any cause. Pretransplant immunological evaluation: All recipients underwent ABO group compatibility. Complement-dependent cytotoxicity crossmatch was performed for all donor-recipient pairs prior to transplantation. Flow cytometry and donor-specific antibody (DSA) testing were not routinely available during the study period and were performed selectively based on clinical indication and resource availability.
Induction immunosuppression was chosen based on immunological risk assessment, donor type, and prior sensitization history. Induction immunosuppression consisted of anti-thymocyte globulin (ATG) administered at a dose of 1–2 mg/kg for 1–2 days or Basiliximab 20 mg on day 0 and day 4 post-transplant according to institute protocol. ATG was preferentially used in recipients considered to be at higher immunological risk, including those with prior blood transfusions, deceased donor transplantation. Maintenance immunosuppression included a calcineurin inhibitor (tacrolimus or cyclosporine), antimetabolite (mycophenolate mofetil and azathioprine), and prednisolone. Tacrolimus trough targets were 8–10 ng/mL for the first 3 months, 6–8 ng/mL for months 4–12 and 4–6 ng/mL thereafter; when cyclosporine was used, trough targets were 200–300 ng/mL (0–3 months), 150–300 ng/mL (4–12 months) and 100–150 ng/mL thereafter.
Statistical analysis
Continuous variables were expressed as median with interquartile range (IQR) or mean ± standard deviation, as appropriate based on data distribution. Categorical variables were summarized as frequencies and percentages. Survival outcomes were estimated using Kaplan-Meier analysis. Statistical analysis performed using SPSS 23.
Ethical considerations
The study was approved by the Institutional Ethics Committee (IEC No: 20102025, dated 14.10.2025). The requirement for informed consent was waived due to the retrospective nature of the study. No external funding was received for this work, and the authors declare no conflicts of interest.
Results
Recipient demographics
The baseline demographic and pretransplant details of the pediatric recipients are summarized in Table 1. Most children were adolescents with a predominance of males and hemodialysis as the pretransplant modality of dialysis.
| Parameter | Value/Frequency |
|---|---|
| Age at transplantation (years) | 14.92 ± 2.72 |
| Current age (years) (n = 39) | 21 ± 6.09 |
| Weight (kg) | 36.74 ± 12.5 |
| Height (cm) | 143.6 ± 17.72 |
| Body mass index (kg/m2) | 17.39 ± 4.14 |
| Males | 33 (62.26) |
| Pre-transplant nephrectomy | 3 (5.66) |
| Living donor transplant | 50 (94.34) |
| ABO compatible | 52 (98.11) |
| Pre-emptive transplant | None |
| Dialysis vintage (months) | 12.19 ± 11.59 |
| Pre-transplant hemoglobin (g/dL) | 9.3 ± 2.29 |
| Pre-transplant blood transfusion | 27 (50.94) |
| No. of pre-transplant transfusions | 1.51 ± 1.88 |
| Pre-transplant viral infections | |
| Hepatitis C | 3 (5.66) |
| Hepatitis B | 1 (1.89) |
| Last follow-up (months) | 64.7 (72)# |
Figures in parentheses denote percentages. #median (IQR)
Native kidney disease profile of the recipients
Primary glomerular diseases were the leading etiology seen in 20 patients (37.7%), with focal segmental glomerulosclerosis (16.9%), chronic glomerulonephritis (11.3%), IgA nephropathy (5.7%), and C3 glomerulonephritis (3.8%) as the main subtypes. Congenital anomalies of the kidney and urinary tract accounted for 14 cases (26.4%), predominantly vesicoureteric reflux (16.9%), posterior urethral valves (5.7%), and dysplastic kidneys (3.8%). Hereditary nephropathies contributed to 6 cases (11.3%), including Alport syndrome (5.7%), juvenile nephronophthisis (3.8%), and primary hyperoxaluria (1.9%). Obstructive uropathy due to neurogenic bladder was noted in 2 patients (3.8%), while thrombotic microangiopathy (TMA) causes, like snake bite TMA and atypical hemolytic uremic syndrome, accounted for 2 cases (3.8%). The etiology remained unknown in 9 children (17%). Among patients with focal segmental glomerulosclerosis (FSGS) (n = 9), no clear cases of biopsy-proven FSGS leading to graft loss were identified during follow-up. However, the possibility of subclinical recurrence cannot be entirely excluded, given the lack of routine biopsies. Genetic testing was not routinely performed in our cohort due to limited availability and resource constraints during the study period.
Donor characteristics
The mean donor age was 43.32 ± 8.37 years, with a mean body mass index of 24.04 ± 2.33 kg/m2. Females comprised 81.13% of donors, most being mothers (66.04%), followed by fathers (15.09%), grandmothers (13.21%), and deceased donors (5.66%).
Immunosuppressive drug protocols
Induction immunosuppression was administered in 29 patients (54.72%), most commonly anti-thymocyte globulin in 22 patients (41.51%), followed by basiliximab in 7 patients (13.21%). Tacrolimus was used in 34 patients (64.15%) and cyclosporine in 19 recipients (35.85%). Mycophenolate mofetil (50.94%) and azathioprine (49.06%) were equally utilized. All patients received prednisolone. CNI toxicity was observed in 13.21%.
Surgical and perioperative outcomes
All ureteroneocystostomies were performed via the extravesical approach. Most donor kidneys had single arteries (94.34%) and single veins (92.45%). The internal iliac artery was the most common arterial anastomosis site (67.92%), and the external iliac vein was the predominant venous anastomosis site (75.47%). Post-op surgical complications occurred in 26.42% of recipients, including lymphocele (7.55%), urine leak (5.66%), surgical site infection (3.77%), and renal artery thrombosis (1.89%). The mean serum creatinine at discharge was 0.93 ± 0.43 mg/dL. DGF occurred in 8 patients (15.1%), requiring a mean of 3.38 ± 4.34 dialysis sessions. Acute tubular injury (n = 3), antibody-mediated rejection (n = 3), Renal artery thrombosis (n = 1), and acidosis post-surgery (n = 1) were the causes of DGF.
Rejection episodes
At least one biopsy-proven rejection episode occurred in 18 patients. Antibody-mediated rejection (ABMR) was the predominant type (n=15), followed by T-cell-mediated rejection (TCMR, n=5) and mixed forms. Most rejection episodes occurred within the first year post-transplant. The median time to occurrence of second rejection was 48 (15.8-69) months. All biopsy-proven rejection episodes were managed according to institutional protocol. TCMR was treated with pulse intravenous methylprednisolone, while steroid-resistant cases received ATG. ABMR was managed with plasmapheresis and intravenous immunoglobulin.
Infections
More than half of the recipients experienced at least one infection episode during follow-up, most within the first-year post-transplant, as summarized in Table 2. Urinary tract infections and respiratory infections were the leading causes, followed by acute gastroenteritis, cytomegalovirus, and BK virus infections.
| Infection type | Frequency (%) | Time from transplant (months) |
|---|---|---|
| Acute gastroenteritis | 6 (11.32) | 2.87 ± 10.97 |
| Urinary tract infection (UTI) | 9 (16.98) | 1.26 ± 3.92 |
| Graft pyelonephritis | 3 (5.66) | 0.75 ± 4.95 |
| Respiratory tract infection | 6 (11.32) | 3.14 ± 18.35 |
| Cytomegalovirus (CMV) infection | 3 (5.66) | 1.25 ± 8.25 |
| BK virus (BKV) infection | 3 (5.66) | 0.85 ± 3.83 |
Allograft biopsy findings
Allograft biopsies were performed in 30 recipients (56%), yielding a total of 40 biopsy samples. Nine patients (17%) underwent more than one biopsy during follow-up. The most frequent histopathological diagnosis was ABMR (28%), followed by TCMR (15%), combined rejection (3.7%), and calcineurin toxicity (13%). Graft pyelonephritis is seen in 5.6% of biopsies: acute interstitial nephritis, BK nephropathy, and cytomegalovirus are noted in isolated cases.
Post-transplant long-term complications
Pre-transplant hypertension was present in 88.7% of children. Hypertension resolved in 22.6% post-transplant, while new-onset hypertension developed in 11.3%. Post-transplant diabetes mellitus was observed in 7.6% of recipients. Other late complications were post-transplant erythrocytosis (5.7%) and transplant renal artery stenosis (1.9%).
Long-term graft and patient outcomes
Follow-up data were available for all recipients with a median follow-up duration of 64.7 months. The overall mean serum creatinine at last follow-up was 1.83 ± 1.11 mg/dL. The Kaplan-Meier analysis demonstrated excellent early outcomes with progressive decline over time. At 1, 5, and 10 years, graft survival rates were 96.2, 75, and 56%, respectively. At the 5 and 10-year time points, 36 and 25 recipients, respectively, had completed the corresponding duration of follow-up, while others were censored before these intervals. The 1, 5, and 10-year graft survival rates and corresponding patient survival rates are summarized in Table 3 and illustrated in Figures 1.
| Parameter | Value (%) |
|---|---|
| Estimated glomerular filtration rate at last follow-up (ml/min/1.73 m2) (n = 37) | 32.4 ± 14.6 |
| 1-year graft survival (n = 53) | 51 (96.23) |
| 5-year graft survival (n = 36) | 27 (75.00) |
| 10-year graft survival (n = 25) | 14 (56.00) |
| Died with functioning graft | 9 (16.98) |
| Patient survival at last follow-up | 39 (73.58) |
Discussion
Our 20-year single-center experience showed that pediatric renal transplantation in a resource-limited setting has achieved excellent short-term graft survival, with acceptable long-term outcomes. The 1-year graft survival rate of 96.23% in our series is comparable to other Indian pediatric transplant studies, such as Gulati et al. (97% at 1 year),6 the Aster Medcity series (94% at 1–3 years),2 and is on par with large international studies reporting 92–98% survival at 1 year.7,8
The 5-year graft survival in our study was 75%, which is comparable to other Indian centers (70–80%),4,5 but remains lower than the >85% reported from high-income countries.9,10 Our 10-year graft survival of 56% is again comparable with Indian long-term data,3,5 but it is lower when compared to high-income countries.7,11 These differences are mainly attributable to factors like infections and higher rates of ABMR.
Rejection occurred in 34% of our patients, with the majority being ABMR. This proportion of ABMR is similar to recent Indian reports4,6 but higher than in some western countries, where TCMR is still more common.12 The higher proportion of ABMR observed in our study may be related to the limited availability of routine pretransplant donor-specific antibody testing and prior sensitization from blood transfusions. These findings highlight the need for strengthening immunological risk stratification and post-transplant monitoring to further improve long-term graft outcomes in similar settings. Also, 45% of our patients did not receive induction therapy, a practice different from many western countries, where the majority are transplanted with an induction agent.13 In our study, although most acute rejection episodes were successfully treated, the presence of ABMR and recurrent rejection likely contributed to the observed decline in long-term graft survival.
Infections remain a major post-transplant challenge in our center, occurring in 58.5% of recipients. Urinary tract infections and respiratory tract infections were the most frequent, consistent with other Indian series.2,5,14 Infections were more frequent in the ATG group (68.2%) than in the basiliximab group (42.9%). At the last follow-up, patient survival in the basiliximab group was 100% compared to 59.1% in the ATG group. However, the basiliximab group had a shorter duration of follow-up, and the study was not powered for formal statistical comparison.
The DGF rate in our study is 15.1%. The observed DGF was largely attributable to acute tubular injury, early antibody-mediated rejection, and vascular complications. The inclusion of deceased donor transplants, longer dialysis vintage prior to transplantation, and limited pre-transplant immunological risk stratification during earlier years of the study may have contributed to this finding.
Our study also highlights the difference in donor characteristics. The predominance of maternal donors (66%) and female donors overall (81%) mirrors trends in Indian pediatric programs, reflecting sociocultural patterns and family willingness.15
The strengths of our study include long follow-up and detailed documentation of both graft and patient outcomes, allowing good comparison with already existing literature. However, our study has limitations like the retrospective design, single-center setting, relatively small sample size, and lack of routine DSA monitoring or protocol biopsies, which may limit generalizability.
In conclusion, pediatric kidney transplantation in our public-sector program achieved excellent early graft survival comparable to national and international benchmarks. Continued improvements in infection control, immunological risk assessment, and long-term follow-up are essential to enhance sustained graft survival and patient outcomes.
Pediatric renal transplantation in our center demonstrated excellent short-term graft survival and satisfactory long-term outcomes. Areas requiring attention include meticulous immunosuppressive monitoring, early identification and management of rejection, and continued follow-up during the transition from childhood to adulthood.
Author contributions
Conceptualization: AP, JS, BT, GN; Data collection, writing original draft: AP, RL, PR, CS, SVS, MS; Study design and methods development: AP, RL, PR, CS, SVS, MS, DT, SR, SSA, SM, JS, BT, GN; Critical revision and editing, supervision, project administration: DT, SR, SSA, SM, JS, BT, GN. All authors provided final approval to the work.
Conflicts of interest
There are no conflicts of interest.
The authors declare that no generative AI or AI-assisted tools were used in drafting, editing, or preparing this manuscript.
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