BACKGROUND: There has been a recent trend towards starting dialysis at higher estimated glomerular filtration rates (eGFRs) in children, with no identified survival benefits. We aimed to determine whether there are similar trends in the timing of preemptive kidney transplant and whether higher eGFR (≥15 ml/min/1.73 m2) at preemptive kidney transplant was associated with clinical outcomes among US children. METHODS: We performed a retrospective cohort study of 1,514 children in the United States Renal Data System who received a preemptive kidney transplant between 2006-2019. In primary analysis, we examined the association between calendar year and eGFR (ml/min/1.73 m2) at the time of preemptive kidney transplant, categorized as higher (eGFR ≥15) versus lower (eGFR <
15) using logistic regressions. The relationship between eGFR at preemptive kidney transplant and graft failure or death was assessed using Cox proportional hazards and Fine-Gray models. RESULTS: We found a temporal trend in eGFR at preemptive kidney transplant in children
every five-year increase in calendar period was associated with 55% higher odds (95% confidence interval [CI] 1.35-1.79) of receiving a preemptive kidney transplant at higher eGFR. There was no association between preemptive kidney transplant at higher (versus lower) eGFR and the risk of allograft failure or death (hazard ratio [HR] 1.12, 95% CI 0.87-1.43) over a median follow-up of 5.7 years. CONCLUSION: There has been a trend towards preemptive kidney transplant at higher eGFR over time in children. Receipt of a preemptive kidney transplant at higher eGFR was not associated with allograft or patient survival. Implications of these trends deserve further study.