Kidney transplantation offers children with end-stage renal disease (ESRD) significantly longer survival and better quality of life compared to dialysis. In the past decade, pediatric kidney transplantation (pKTx) has developed rapidly in mainland China, driven by development of the new national organ donation and transplantation program, utilization of small pediatric deceased donor kidneys, and a pivotal national allocation policy prioritizing pediatric organs for pediatric recipients ("P to P" policy). These achievements are also inseparable from the dedicated OPO professionals and altruistic donor families. Pediatric donor kidneys are preferentially allocated to pediatric patients nationwide through the China Organ Transplant Response System (COTRS), resulting in accomplishment of 761 pKTx in 2024. This demonstrates transparency and equity in organ allocation. Pediatric donor kidneys with minimal chronic damage have longer expected functional lifespan. Pediatric-to-pediatric transplantation offers advantages in anatomical compatibility-including age, body weight, and kidney size-although it requires high-level technical skills in organ procurement, bench surgery, and vascular anastomosis. Standard extraperitoneal approaches of implantation simplifies surgery and avoids intraperitoneal approaches and perfusion-related complications commonly seen in pKTx from adult kidneys. Due to better size matching, pediatric donor kidneys allow small ESRD children with body weight of 5-10Kg to receive KTx when necessary. Surgical complications increase with younger donor and recipient age. The "P to P" policy ensures such technically demanding cases are allocated to experienced transplant centers, improving transplant outcomes and supporting the development of centralized pKTx programs. Our center performs 60–80 pKTx annually, with a median donor age of 30 months and body weight of 12.1 kg. About 20% of recipients are under 5 years old, with the youngest being 8 months and 5.4 kg. We will optimize utilization of small pediatric donor kidneys to further improve graft survival. Strengthening regional collaboration is strongly advocated to better support ESRD children in the Greater Bay Area.
