- Design
- retrospective single-centre cohort with CUSUM 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
- one-year graft survival, acute rejection, thrombosis and delayed graft function
- Effect
- graft survival 73.1% vs 100% (p<0.001); acute rejection 19.2% vs 2.0% (p=0.026); pooled meta-analysis one-year graft survival 91%, patient survival 98%
Kidneys from donors weighing 15 kg or less, or under three years old, are frequently declined or used only as en bloc grafts, which halves the number of recipients they serve. This single-centre cohort transplanted 77 children between October 2022 and May 2026 — 26 from small donors as single kidneys, 51 from larger donors — and added a meta-analysis of seven studies covering 527 patients.
The raw comparison looks discouraging. One-year graft survival was 73.1% with small donors against 100% with larger ones, and acute rejection 19.2% against 2.0%. Thrombosis, delayed graft function and patient survival were similar, and estimated GFR at one year was comparable between groups — so the grafts that survived functioned as well.
The learning curve is the point of the paper. CUSUM analysis showed an inflection at case 16, with operative time falling from 187.6 to 146.3 minutes. Early graft losses concentrated before that point. The pooled meta-analysis across centres, most of which are past their learning phase, gives one-year patient survival 98%, graft survival 91%, thrombosis 5%, delayed graft function 13% and acute rejection 10% — numbers that are acceptable rather than alarming. So the technique works; it is the first fifteen attempts that carry the cost, which is an argument for concentrating these transplants in few centres rather than spreading them.
- A centre starting this programme should expect graft losses in its first fifteen cases and consent families accordingly.
- Single-kidney rather than en bloc use of small donors doubles the recipients each donor serves — the reason to persist with the technique.
- Acute rejection at 19.2% versus 2.0% suggests immunosuppression may need to differ for these grafts, which this study does not address.
- India's paediatric deceased-donor programme is small and highly centralised; this supports keeping it that way for small donors.
- Function among surviving grafts matched larger-donor kidneys at one year, which is the reassuring half of the result.
Why it matters
Small paediatric donor kidneys are routinely declined, and this quantifies what a centre pays to develop the capability.
Don't overread it
Twenty-six small-donor transplants at one centre — the learning-curve inflection at case 16 is a description of this centre, not a threshold other units should expect.
The statistics, in plain English
A one-year graft survival of 100% in 51 larger-donor recipients is implausibly perfect and signals a highly selected single-centre cohort, which makes the 73.1% comparison look worse than it would against a realistic benchmark. Twenty-six patients is far too few to characterise a learning curve, and CUSUM analysis identifies an inflection point in retrospect from the data it is given — case 16 is where this centre's curve turned, not a transferable threshold. The meta-analysis figures across 527 patients are the more reliable numbers.
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