SEVERE haemorrhage during paediatric kidney transplantation occurred in 7.3% of cases in a single centre cohort and was associated with significantly reduced five-year graft survival, highlighting important surgical and donor related risk factors.
Severe Haemorrhage in Paediatric Kidney Transplantation
In a retrospective single centre study of 218 children undergoing their first kidney transplant between 2008–2015, severe haemorrhage was identified in 16 cases. Investigators used a data driven cluster analysis to define severe haemorrhage based on high perioperative bleeding volume and blood component requirements. Severe haemorrhage was also defined by the need for reoperation or administration of activated factor VII or fibrinogen for transplant related bleeding.
Thirty-eight exposure variables were analysed, including clinical and laboratory data, donor and recipient characteristics, surgical technical variables, and medications. Unadjusted logistic analyses showed that severe haemorrhage was more frequent among younger and smaller recipients, children receiving kidneys from older donors, and those undergoing transplantation with living donors. A higher graft dose was also associated with increased risk. Among laboratory markers, postoperative platelet count was linked to severe haemorrhage.
Risk Factors for Severe Haemorrhage
The data indicate that donor type and size mismatch play a central role in the development of severe haemorrhage. The combination of small recipients and large donors emerged as a key risk factor. The authors suggest that a larger abdominal dissection area in small children receiving large grafts may contribute to increased bleeding risk.
These findings are notable with regard to surgical planning and donor selection, particularly in smaller children. The frequency of severe haemorrhage observed in this cohort was higher than previously reported in the literature, highlighting the need for careful perioperative assessment.
Impact on Graft Survival and Clinical Outcomes
Severe haemorrhage had important consequences for long term outcomes. Five-year graft survival was significantly lower in children with severe haemorrhage compared with those without: 62.5% versus 91.5%; p<0.001.
Analysis of haemorrhage consequences also considered delayed renal function, length of hospitalisation during transplantation, estimated glomerular filtration rate after transplantation, and five-year patient survival.
Overall, these data emphasise the importance of recognising risk factors for severe haemorrhage in paediatric kidney transplantation and tailoring perioperative strategies to mitigate bleeding risk and improve graft outcomes.
Reference
Maia MLA et al. Perioperative severe hemorrhage in pediatric kidney transplantation: frequency, risk factors, and outcomes. Pediatr Nephrol. 2026; DOI: 10.1007/s00467-026-07391-7.
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