- Design
- single-centre retrospective cohort with cumulative sum learning-curve analysis, plus meta-analysis of seven studies
- Population
- 77 children transplanted October 2022 to May 2026 (26 small-donor, 51 large-donor); meta-analysis of 527 patients
- Primary outcome
- graft and patient survival, acute rejection, thrombosis, delayed graft function and eGFR at 1 year
- Effect
- 1-year graft survival 73.1% vs 100% (P<0.001), acute rejection 19.2% vs 2.0% (P=0.026), comparable 1-year eGFR; learning-curve inflection at case 16; pooled 1-year graft survival 91%
Paediatric donors weighing 15 kg or less are often declined or used only as en-bloc pairs, which halves the number of children a donor can help. This retrospective cohort from a single centre transplanted 77 children between October 2022 and May 2026: 26 received a single kidney from a donor weighing 15 kg or less or aged 3 years or under, and 51 received a graft from a larger donor. A cumulative sum learning-curve analysis and a meta-analysis of seven studies covering 527 patients accompanied it.
The early cost was real. One-year graft survival was 73.1% in the small-donor group against 100%, and acute rejection 19.2% against 2.0%. Thrombosis, delayed graft function and patient survival did not differ, and eGFR at one year was comparable between groups, which says the grafts that survived worked well. The learning curve inflected at the sixteenth case, with operative time falling from 187.6 to 146.3 minutes.
That inflection is the finding, not the survival difference. It says the excess graft loss was concentrated in a centre's first cases rather than being intrinsic to small grafts, and the pooled meta-analysis figures across established series support that: one-year patient survival 98%, graft survival 91%, thrombosis 5%, delayed graft function 13% and acute rejection 10%.
Read the design before acting. Twenty-six against fifty-one patients at one centre, retrospectively compared without adjustment for the differences that determined which child got which organ, cannot support a causal claim about small donors. What it supports is a service-level point: programmes considering this should expect a learning phase, should count it explicitly, and should not judge the technique on their first dozen cases. Where deceased-donor organs are scarce, as they are across most of India, the potential to transplant two children from one small donor is worth that structured start.
- Expect and plan for a learning phase of around 15 cases before judging outcomes with small paediatric donors
- Counsel families about a higher early graft loss and rejection risk, not about long-term function, which was comparable
- Concentrate these cases in a small number of surgeons rather than spreading them across a rota
- Maintain the same vigilance for vascular thrombosis, which did not differ here but remains the classic risk with small grafts
- Treat the 73.1% one-year graft survival as a single centre's early experience, not as the expected result
The statistics, in plain English
With 26 patients in the small-donor group, a difference between 73.1% and 100% rests on roughly seven graft losses, so the estimate is fragile and no confidence interval is given for it. The comparison is retrospective and unadjusted, meaning the children who received small grafts may have differed systematically from those who did not, and nothing in this design separates donor size from those differences. The cumulative sum analysis is the more useful part: it identifies where in a sequence outcomes improved, which is descriptive rather than inferential but maps directly onto how a programme should plan. Pooled meta-analytic figures across 527 patients are more stable than the single-centre numbers and should anchor any counselling.
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