UK Renal Registry: recent data, research and collaboration

As Munro and Faust point out, there appears a stark contrast in the case and mortality rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children compared with...

Journal of Kidney CareVol. 1, No. 2 EditorialFree AccessVariances in peritoneal dialysis outcomes still existMark LambieMark LambieSearch for more papers by this authorMark LambiePublished Online:23 Jul 2016https://doi.org/10.12968/jokc.2016.1.2.56AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail Health professionals assisting with the provision of peritoneal dialysis (PD) have reason to be pleased with the clear improvements seen over time in mortality risk, reported by international registries (Australia and New Zealand Dialysis and Transplant Registry, 2016; Steenkamp et al, 2016; United States Renal Data System, 2015). These advances have come despite difficulties securing funding for meaningful, high-quality randomised controlled trials, and are likely to partially represent the ongoing drive to improve care through audit and quality improvement projects.One clinical area that leaps out as needing these measures is peritonitis, where there is clear evidence of marked variability between centres (Piraino et al, 2011). Although most UK units do run individual audits benchmarked against the target initially set for the first Renal Association guidelines in 1995 (<1 episode per 18 patient months), this represents a disappointing lack of progress, particularly when compared against international standards.The quote attributed to Irish mathematical physicist Lord Kelvin—‘If you cannot measure it, you cannot improve it’—highlights the need for data collection. For peritonitis, this has started to improve with summary data provided for the dashboard returns; however, to move from numerous local audits to one national audit, this needs to become registry data.Technique failure is another major issue for PD patients, as increasing evidence of significant between-centre variability suggests care should be improved. As this is a complex problem, with 39 separate possible reasons for variation (Perl et al, 2016), large studies are required. The Peritoneal Dialysis Outcomes and Practice Patterns Study will be the first to address this complex area. Nevertheless, to prevent patients unnecessarily switching to haemodialysis, registry data is again needed.In light of the aforementioned issues, the latest data requirements for the UK Renal Registry include details about peritonitis episodes and technique failure; however, this will only improve practice if information is added to the databases.To continue improving care for patients, and reduce local audit workload, PD teams need to ensure peritonitis and technique failure is routinely recorded.ReferencesAustralia and New Zealand Dialysis and Transplant Registry (2016) ANZDATA Registry. 38th Report, Chapter 5: Peritoneal Dialysis. http://tinyurl.com/ja5zd4e (accessed 13 July 2016) Google ScholarPerl J, Davies SJ, Lambie M et al. (2016) The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): unifying efforts to inform practice and improve global outcomes in peritoneal dialysis. Perit Dial Int 36(3): 297–307 Google ScholarPiraino B, Bernardini J, Brown E et al. (2011) ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int 31(6): 614–30 Google ScholarSteenkamp R, Rao A, Fraser S (2016) UK Renal Registry 18th Annual Report (December 2015) Chapter 5: survival and causes of death in uk adult patients on renal replacement therapy in 2014: national and centre-specific analyses. Nephron 132(Suppl 1): 111–44 Google ScholarUnited States Renal Data System (2015) USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda: MD Google Scholar FiguresReferencesRelatedDetails 2 July 2016Volume 1Issue 2ISSN (print): 2397-9534ISSN (online): 2397-9542 Metrics History Published online 23 July 2016 Published in print 2 July 2016 Information© MA Healthcare LimitedPDF download

Background and Aims With ageing of the population both prevalence of chronic kidney disease (CKD) and incidence of kidney replacement therapy (KRT) are rising. Existing research suggests that adding a formal diagnosis-code for CKD to the health record in those affected is associated with better implementation of recommended care and fewer hospitalisations for cardiovascular diseases. Furthermore, reliable estimates of the future need of KRT cannot be extrapolated from previous years after the COVID-19 pandemic. This ecological study investigates whether coding for CKD is associated with KRT incidence at clinical commissioning group (CCG) level in England. Method KRT incidence rates for CCGs in England were calculated using UK Renal Registry (UKRR) data from 01/2019 to 12/2021. Data on the percentage of uncoded CKD patients (PUCP) who had laboratory evidence of CKD but lacked a diagnostic code were obtained from the Cardiovascular Disease Prevention Audit (CVDPREVENT), a national primary care audit that extracts routinely held general practitioner (GP) data. The PUCP was modelled both as a continuous and a categorical variable using quintiles with an equally large population in each quintile to investigate potential non-linear associations. Data on potential confounders and acute kidney injury (AKI) mortality as a marker for underlying population frailty were obtained from CVDPREVENT and the UKRR, respectively. A hierarchical conceptual framework was used to assess the association between the PUCP and KRT incidence, in which covariates were grouped into sociodemographic, healthcare quality and health status covariates. Poisson models assessed the association between PUCP and KRT incidence and effect modification by AKI mortality was investigated using a simplified model for which AKI mortality was recoded to a binary variable. Results The crude overall KRT incidence rate was 141.30/1 000 000, ranging from 84.54 to 204.05/1 000 000 in the different CCGs (Fig. 1A). The mean PUCP was 15.47% (SD 5.55), ranging from 3.68% to 30.28%, with no immediately identifiable association with KRT incidence (Fig. 1B). Univariable Poisson regression showed no evidence of an association between the crude PUCP as a continuous measure and KRT incidence (p = 0.886). However, when included as a categorical variable, there was strong evidence (p &amp;lt; 0.001) for a difference in the crude KRT incidence rates, indicating a non-linear association. After adjusting for all covariates, there was evidence for an association between the PUCP as a continuous measure and KRT incidence (RR 1.004, 95% CI 1.000-1.008, p = 0.029). However, the PUCP was also considered as a categorical variable and there was still evidence of a difference in rates (p = 0.030) with the CCGs in the lowest PUCP quintile having a lower KRT incidence than the others. Considering the PUCP as a continuous variable, there was some evidence (p = 0.033) for effect modification: in CCGs with low AKI mortality, there was no evidence of an association between the PUCP and KRT incidence (RR 1.001, 95% CI 0.996-1.005, p = 0.823), whereas a 7% increase in KRT incidence for every 10% increase in uncoded CKD patients was found in CCGs with high AKI mortality (RR 1.007, 95% CI 1.003-1.012, p = 0.024) (Fig. 2A). Considering the PUCP as a categorical variable, there was very strong evidence (p &amp;lt; 0.001) for effect modification by AKI mortality: In CCGs with low AKI mortality, there was no evidence that rates were different in higher quintiles of the PUCP compared to the lowest. However, in CCGs with high AKI mortality, KRT incidence rates from the second up to the fifth quintile of the PUCP were between 10.3% and 18.5% higher than in the first quintile (Fig. 2B). Conclusion At a geographical level in England, the data suggest that the prevalence of not having formally diagnosed CKD is non-linearly associated with a higher KRT incidence rate, especially in areas with a high AKI mortality. The PUCP can be seen as a proxy for care quality. Therefore, improved care quality might be associated with lower KRT incidence rates. After the COVID-19 pandemic, PUCP follow-up data may be the first way to estimate future KRT needs and support the planning process.

Aims Rare kidney diseases need better understanding and the starting point is collection of clinical data. Therefore our centre is participating in RaDaR which is a UK Renal Association initiative designed to gather information. RaDaR recruitment began in 2010 and now covers more than 40 conditions. There are around 10 000 recruits from 78 renal adult and paediatric units in the UK. Our Paediatric Renal Centre is the leading recruiting hospital in the UK. To describe the range of range of conditions and patient numbers recruited to RADAR at BCH which is a national tertiary renal referral hospital in the UK. Methods The RaDaR dataset is defined by the UK Renal Registry in association with the Rare Disease Groups, made up of experts in each eligible condition. Data fields include demographics, blood and urine results, medications, transplant and dialysis history, genetics and co-morbidities. Data is entered retrospectively from the patient’s medical records following consent. Results 319 patients have been consented at BCH. The age range is from birth to 16 years with mean of 4.9 years with male to female ratio of 55%:45%. The most common condition is Idiopathic Nephrotic Syndrome (n=128; 39%), followed by Alport Syndrome (n=33; 10%), ARPKD (n=25; 8%), Hyperoxaluria (n=24; 7%) and STEC HUS (n=22; 7%). The other conditions with numbers of patients recruited so far include: ADPKD (n=14), aHUS (n=13); Cystinosis (n=9); Cystinuria (n=3); Dent and Lowe (n=7); HNF1b (n=6); Hypokalaemic Alkalosis (n=8); MPGN (n=14) and Vasculitis (n=7). Conclusion RaDaR provides important epidemiology data based on the whole country population which is shared amongst the renal team to develop further research into rare kidney diseases and improve the quality of care for these patients. It also gives an opportunity to define the best treatment practices across the country in the future.

Background and Aims Chronic kidney disease (CKD) represents a major global healthcare challenge, affecting approximately 850 million people worldwide [1], and is an independent risk factor for the progression to kidney replacement therapy (KRT) and all-cause mortality [2]. However, CKD encompasses various causes, each with unique pathophysiology and rates of progression [3]. Here we describe the outcomes from NURTuRE-CKD, an ongoing, multicenter prospective cohort study of 2996 non-dialysis CKD patients, by primary renal diagnosis, aiming to describe the differing rates of progression, ESKD and mortality by CKD cause and provide insights into those at greatest risk. Method Patients with an eGFR of 15–59 mL/min/1.73 m2 or eGFR ≥60 mL/min/1.73 m2 with a uACR &amp;gt;30 mg/mmol were enrolled, in addition to 86 controls. The full study design and methods of NURTuRE-CKD have previously been reported [4]. Outcomes: ESKD, eGFR &amp;lt;15 mL/min/1.73 m2, Transplantation, initiation of KRT, all-cause mortality and serial eGFR data were sourced from the UK Renal Registry. ESKD was defined as initiation of KRT or eGFR &amp;lt;15 mL/min/1.73 m2. Rate of progression was determined via eGFR slope. ERA diagnostic categories were used for primary renal diagnoses, with ‘glomerular diseases’ split into glomerulonephritis (GN) and vasculitis. The Chi-squared test was used to compare categorical variables, and the Kruskal-Wallis test for continuous variables. A multivariable Cox proportional hazards regression analysis predicting the time to ESKD by primary diagnosis was undertaken, using vasculitis as the reference category. Model 2 included adjustments for baseline eGFR. Results Table 1 depicts both the baseline characteristics and outcomes by the 8 diagnosis categories. Average follow-up duration was 53.8 months, not significantly different between the groups, but all other baseline variables differed significantly. The hypertensive/renovascular group were oldest and familial group youngest at 71 and 53 years, respectively. At baseline the diabetic nephropathy (DN) group had the lowest eGFR 28 ml/min/1.73 m2 and highest uACR 88.3 mg/mmol. However, the familial group had the steepest pre-enrolment eGFR decline slope. Delta eGFR during the follow-up period was steepest in the familial group and DN groups at −3.4 and −3.0 ml/min/1.73 m2, respectively, whereas the vasculitis group had slowest progression −0.7 ml/min/1.73 m2. Overall rate of ESKD was 24.7%; lower in the vasculitis (14%), systemic disease (17.7%) and tubulointerstitial (18.8%) groups, and higher in the DN (36.7%) and familial (31.6%) groups. All-cause mortality was greatest in the DN group at 40.4%. Despite being the fastest progressors defined by eGFR slope, the familial group had the lowest mortality rate (5.2%), but they were of younger age and had a high rate of kidney transplantation (10.1%). Unadjusted HRs for ESKD, were significantly higher for all diagnoses except tubulointerstitial and systemic diseases compared to the vasculitis group; DN evidenced the highest hazard ratio at 3.15 (2.18-4.55). When adjusted for baseline eGFR, HRs for the glomerulonephritis 2.04 (1.89-4.03), diabetes 1.5 (1.04-2.16) and familial 2.76 (1.89-4.03) remained significantly higher. Conclusion Rates of progression and incidence of clinically meaningful outcomes differ between CKD causes in NURTuRE. Those with DN and familial conditions had faster eGFR decline and had higher rates of ESKD, with associations persisting despite controlling for baseline eGFR. Recognising that CKD progresses at different rates is crucial, not only for providing personalised care, but also key to understanding differing pathophysiologic mechanisms of progression. NURTuRE-CKD will also explore novel biomarkers, with the aim of illuminating mechanisms of progression, improving risk prediction and highlighting novel drug targets.

Introduction: Blood pressure (BP) control is assessed annually from patients on Renal Replacement Therapy at renal centres in England, Wales and Northern Ireland by the UK Renal Registry. Methods: Patients alive and receiving RRT on 31st December 2007 with a BP reading in either the fourth or third quarter of 2007 were included. Summary statistics were calculated for each renal centre, nation and renal disease category. Linear regression analyses were performed for prevalent patients between 2000 and 2007. Results: Significantly more haemodialysis patients achieved the BP standard (44.6% pre-HD and 48.8% post-HD) than peritoneal dialysis (32.8%) or renal transplant patients (26.7%). Median BP fell significantly between 2000 and 2007 for each treatment modality. There was significant variability in BP control between renal centres (p < 0.0001) for haemodialysis and transplant patients. Hypertension was significantly more common in haemodialysis patients with vascular disorders such as diabetes and renovascular disease (56.8%) than in glomerulonephritis (51.0%) or tubular disorders (45.1%). The effect was less prominent in peritoneal dialysis and not evident in transplant patients where few achieved the BP standard. Conclusion: A minority of patients on RRT achieved BP standards in 2007. There remained a significant variation in achievement of standards between renal centres.

UK Renal Registry 18th Annual Report: Appendix G UK Renal Registry dataset specification

Background Clinical epidemiology data for young adults on renal replacement therapy (RRT) are lacking. While mostly transplanted, they have an increased risk of graft loss during young adulthood. Methods We combined the UK Renal Registry paediatric and adult databases to describe patient characteristics, transplantation and survival for young adults. We grouped patients 11-30 years of age starting RRT from 1999 to 2008 by age band and examined their course during 5 years of follow-up. Results The cohort (n = 3370) was 58% male, 79% white and 29% had glomerulonephritis. Half (52%) started RRT on haemodialysis (HD). Most (78%) were transplanted (18% pre-emptive, 61% as second modality); 11% were not listed for transplant. Transplant timing varied by age group. The deceased:living donor kidney transplant ratio was 2:1 for 11-<16 year olds and 1:1 otherwise. Median deceased donor transplant waiting times ranged from 6 months if <16 years of age to 17 months if ≥21 years. Overall 8% died, with being on dialysis and not transplant listed versus transplanted {hazard ratio [HR] 16.6 [95% confidence interval (CI) 10.8-25.4], P < 0.0001} and diabetes versus glomerulonephritis [HR 4.03 (95% CI 2.71-6.01), P < 0.0001] increasing mortality risk. Conclusions This study highlights the frequent use of HD and the importance of transplant listing and diabetes for young adults. More than half the young adults in our cohort started renal replacement therapy on HD. One in 10 young adults were not listed for transplant by 5 years and were ∼20 times more likely to die than those who were transplanted. Diabetes as a primary renal disease was common among young adults and associated with increased mortality. Overall, almost 1 in 10 young adults had died by 5 years from the start of RRT.

End-stage renal disease is a long-term irreversible decline in kidney function requiring kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation followed by induction and maintenance immunosuppressive therapy to reduce the risk of kidney rejection and prolong graft survival. To systematically review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect,(®) Novartis Pharmaceuticals) and rabbit antihuman thymocyte immunoglobulin (Thymoglobuline,(®) Sanofi) as induction therapy and immediate-release tacrolimus [Adoport(®) (Sandoz); Capexion(®) (Mylan); Modigraf(®) (Astellas Pharma); Perixis(®) (Accord Healthcare); Prograf(®) (Astellas Pharma); Tacni(®) (Teva); Vivadex(®) (Dexcel Pharma)], prolonged-release tacrolimus (Advagraf,(®) Astellas Pharma); belatacept (BEL) (Nulojix,(®) Bristol-Myers Squibb), mycophenolate mofetil (MMF) [Arzip(®) (Zentiva), CellCept(®) (Roche Products), Myfenax(®) (Teva), generic MMF is manufactured by Accord Healthcare, Actavis, Arrow Pharmaceuticals, Dr Reddy's Laboratories, Mylan, Sandoz and Wockhardt], mycophenolate sodium, sirolimus (Rapamune,(®) Pfizer) and everolimus (Certican,(®) Novartis Pharmaceuticals) as maintenance therapy in children and adolescents undergoing renal transplantation. Clinical effectiveness searches were conducted to 7 January 2015 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science [via Institute for Scientific Information (ISI)], Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (HTA) (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted to 15 January 2015 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Databases (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and EconLit (via EBSCOhost). Titles and abstracts were screened according to predefined inclusion criteria, as were full texts of identified studies. Included studies were extracted and quality appraised. Data were meta-analysed when appropriate. A new discrete time state transition economic model (semi-Markov) was developed; graft function, and incidences of acute rejection and new-onset diabetes mellitus were used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. Three randomised controlled trials (RCTs) and four non-RCTs were included. The RCTs only evaluated BAS and tacrolimus (TAC). No statistically significant differences in key outcomes were found between BAS and placebo/no induction. Statistically significantly higher graft function (p < 0.01) and less biopsy-proven acute rejection (odds ratio 0.29, 95% confidence interval 0.15 to 0.57) was found between TAC and ciclosporin (CSA). Only one cost-effectiveness study was identified, which informed NICE guidance TA99. BAS [with TAC and azathioprine (AZA)] was predicted to be cost-effective at £20,000-30,000 per quality-adjusted life year (QALY) versus no induction (BAS was dominant). BAS (with CSA and MMF) was not predicted to be cost-effective at £20,000-30,000 per QALY versus no induction (BAS was dominated). TAC (with AZA) was predicted to be cost-effective at £20,000-30,000 per QALY versus CSA (TAC was dominant). A model based on adult evidence suggests that at a cost-effectiveness threshold of £20,000-30,000 per QALY, BAS and TAC are cost-effective in all considered combinations; MMF was also cost-effective with CSA but not TAC. The RCT evidence is very limited; analyses comparing all interventions need to rely on adult evidence. TAC is likely to be cost-effective (vs. CSA, in combination with AZA) at £20,000-30,000 per QALY. Analysis based on one RCT found BAS to be dominant, but analysis based on another RCT found BAS to be dominated. BAS plus TAC and AZA was predicted to be cost-effective at £20,000-30,000 per QALY when all regimens were compared using extrapolated adult evidence. High-quality primary effectiveness research is needed. The UK Renal Registry could form the basis for a prospective primary study. This study is registered as PROSPERO CRD42014013544. The National Institute for Health Research HTA programme.

IntroductionUse of home dialysis by centres in the UK varies considerably and is decreasing despite attempts to encourage greater use. Knowing what drives this unwarranted variation requires in-depth understanding of...

Background: The central paradigm of effective peritoneal dialysis (PD) is an appropriate standard of PD catheter function. Aim: The aim of the project was to develop an effective national PD access audit which would identify an ‘appropriate standard' of PD catheter function. Methods: The UK Renal Registry collected centre specific information on various PD access outcome measures including catheter functionality and post-insertion complications. The first PD access audit covering England, Northern Ireland and Wales was conducted during April to June 2012 looking at incident dialysis patients in 2011. Results: Forty three data collection spreadsheets were returned from a total of 65 centres describing 917 PD catheter placements. The median age of PD patients was 61 years and 61.5% were male. The proportion of patients initiated on PD in comparison to HD was lower in socially deprived areas. There was a relationship between the timing of nephrology referral and the likelihood of surgical assessment regarding PD catheter placement. Patients with diabetes did not have higher rates of PD catheter failure or of early peritonitis. Conclusions: A comparative PD catheter audit has the potential to provide valuable information on an important patient related outcome measure and lead to an improvement in patient experience. There was wide variation between centres of PD catheter use for late presenting patients. Overall patients were more likely to get a PD catheter if they had been known to the service for more than 1 year. The percutaneous insertion technique was associated with a higher early (less than 2 week) peritonitis rate and more catheter flow problems.

Morbidity and mortality of patients undergoing renal replacement therapy is influenced by the adequacy of correction of renal anaemia. The Renal Association has set standards for attainment of a target haemoglobin of 10 g/dl. This study compared the management of anaemia in dialysis patients in nine renal units in the UK. A cross-sectional analysis was carried out on data submitted electronically to the UK Renal Registry. There were 1449 haemodialysis patients and 741 peritoneal dialysis patients in the nine renal centres analysed. Individual patient data were collected on haemoglobin, ferritin, erythropoietin prescription, and pre- and post-dialysis urea concentrations. None of the centres achieved the standard of more than 80% of haemodialysis patients with a haemoglobin of greater than 10 g/dl. Three centres achieved this standard for peritoneal dialysis. There was wide variation between centres in the percentage reaching the target. Differences in ferritin, erythropoietin prescription, and dialysis doses between centres could not entirely explain the variations between centres. Females had lower haemoglobin than males despite a greater proportion being treated with erythropoietin. There was a trend of increasing haemoglobin concentration during the study period in haemodialysis but not in peritoneal dialysis patients. The Renal Association standards for management of anaemia are not being met. The data allow renal centres to compare their practices with others to identify areas that might be improved. Further analysis may allow a benchmark to be determined of what it is possible to achieve by best practice.

Background and Aims Incidence of Acute Kidney Injury (AKI) is known to be seasonal, peaking in winter months among hospitalised patients. Previous studies have suggested that the seasonality of AKI is likely to be influenced by the seasonality of the underlying acute illnesses that are associated with AKI. Mortality of patients with AKI has also been reported as being higher in winter, reflecting well-described excess winter mortality associations. Here we describe the seasonal variations of AKI alerts in England and the associated mortality rate using linked national databases. Method Serum creatinine changes compatible with KDIGO AKI stage 1, 2 and 3 are sent by laboratories in England as AKI alerts to the treating clinicians and the UK Renal Registry (UKRR). We linked the electronic AKI alerts to the Hospital Episode Statistics (HES) data, to identify patients who were hospitalised. We carried out descriptive statistics, and investigate the seasonal effect to the 30-day patient mortality from date of getting AKI alert, using multivariable Cox regression and sequentially adjusting for age, sex, Index of multiple deprivation (IMD) and peak AKI stage Results Winter has the highest number of AKI episodes (N=81,276), which is 6% higher than that in summer (N=76,329) (Table 1). For patients who had an AKI episode and admitted to hospitals, the crude 30-day mortality is higher in the winter season when compared to the summer [HR 1.28 (1.25-1.31), p&amp;lt;0.01] (Figure 1). After adjusting season by age, peak AKI stage, IMD and sex, winter season still has significantly higher 30-day mortality than summer [HR 1.24 (1.21-1.27), p&amp;lt;0.01]. Winter mortality peak is confounded by age and AKI severity, which explained the drop of hazard ratio at winter peaks; whereas season is not confounded by deprivation and sex. The pattern of seasonality varies with age, in age group 18-39, there were 26.1% of AKI episodes in summer and 23.3% in winter, whereas in age group &amp;gt;75, there were 23.7% in summer and 27.1% in winter. Conclusion Analysis of England data confirms seasonal peak in AKI during winter months. Additionally it shows increased risk of mortality for patients with AKI in winter months. Future work will investigate the impact of comorbidities and case-mix on outcomes. By understanding the seasonal variation of AKI, we can potentially plan preventive care and improve clinical practice.

Inequality of access to home therapies in the UK for ethnic minorities and areas with high levels of social deprivation: results from the UK Renal Registry

Background and Aims Multiple international studies report young adulthood is associated with kidney transplant loss. However, there are few published UK graft survival data for children and young adults. To our knowledge, no studies assess initial transplant function or examine declining function, when interventions may improve outcomes. We aimed to report graft survival for UK children and young adults and to explore the importance of donor and recipient variables on graft loss and rate of decline. Method Retrospective cohort study using UK Renal Registry and NHS Blood and Transplant data, including patients aged &amp;lt;30 years who underwent kidney transplantation between 1998-2016. Univariate analyses included Kaplan-Meier survival curves and log-rank tests. Multivariable analyses used Cox proportional hazards to investigate variables associated with death-censored graft failure in a conditional risk-set model for multiple failure data. Age group was time-varying. We used the Efron method for ties, stratification by graft number and clustering at participant level. We calculated estimated glomerular filtration rate (eGFR) using the Schwartz formula if aged &amp;lt;18 years and the 4-variable Modification of Diet in Renal Disease formula otherwise. For participants with ≥4 values outside the first 6 months, individual regressions of eGFR against time were performed. We undertook multivariable linear regression to establish associations with eGFR slope gradients. Results We studied 5121 individuals. Of these, 371 received a further transplant during the study period. There were 1371 graft failures and 145 deaths with a functioning graft over a 39541-year risk period. The cohort was 61% male and 80% white. Most (36%) had structural kidney problems, followed by glomerulonephritides (29%). Live donation occurred in 48%, donation after brainstem death in 46% and after circulatory death in 6%. Mean initial eGFR was 62 mls/min/1.73m2. Median graft survival was 7 years. One-year survival was 94.4% (95% confidence interval (CI) 93.7, 95.0), 5-year survival 84.0% (95% CI 82.9, 85.0), 10-year survival 71.1% (95% CI 69.6, 72.5), 15-year survival 60.2% (95% CI 58.1, 62.3) and 20-year survival 51.2% (47.6, 54.7). Survival at 15 years was least at 54.4% (95% CI 49.9, 58.7) in those transplanted at age 15-19 years and most in those transplanted at age 0-4 years at 71.7% (95% CI 63.4, 78.5). Figure 1 displays hazard ratios for graft loss. Protective associations were male gender (p=0.04), living donation (p=0.02) and higher initial eGFR (p&amp;lt;0.0001). Risk associations included adverse human leucocyte mismatches (p=0.001), black ethnicity (p=0.001), young adulthood and glomerulonephritides. Risk associations for faster eGFR decline included female gender (p&amp;lt;0.0001), age group 15-19 years (p=0.04), higher initial eGFR (p&amp;lt;0.0001), additional graft (p=0.003) and transplants during 2011-2014 (p=0.03). Conclusion This study reports long-term graft survival for UK children and young adults and evaluates associations with declining transplant function. It contributes up to 20 years of follow-up and considers initial graft function in addition to established co-variates. Graft survival was ≈60% at 15 years. The study highlights the changing survival by age group over time. Those aged &amp;lt;5 years at transplant had the least initial survival, but best long-term graft survival relative to other age groups. Initial transplant function is strongly associated with graft performance. Similar associations with gender, ethnicity and age group are seen compared with other studies. Young adulthood is a high-risk period for UK patients and interventions are needed to improve outcomes during transition and young adulthood.