One of the main objectives of the European health policy framework is to ensure equitable access to high-quality health services across Europe. Here we examined country-specific kidney transplantation and graft failure rates in children and explore their country- and patient-level determinants. Patients under 20 years of age initiating kidney replacement therapy from January 2007 through December 2015 in 37 European countries participating in the ESPN/ERA-EDTA Registry were included in the analyses. Countries were categorized as low-, middle-, and high-income based on gross domestic product. At five years of follow-up, 4326 of 6909 children on kidney replacement therapy received their first kidney transplant. Overall median time from kidney replacement therapy start to first kidney transplantation was 1.4 (inter quartile range 0.3-4.3) years. The five-year kidney transplantation probability was 48.8% (95% confidence interval: 45.9-51.7%) in low-income, 76.3% (72.8-79.5%) in middle-income and 92.3% (91.0-93.4%) in high-income countries and was strongly associated with macro-economic factors. Gross domestic product alone explained 67% of the international variation in transplantation rates. Compared with high-income countries, kidney transplantation was 76% less likely to be performed in low-income and 58% less likely in middle-income countries. Overall five-year graft survival in Europe was 88% and showed little variation across countries. Thus, despite large disparities transplantation access across Europe, graft failure rates were relatively similar. Hence, graft survival in low-risk transplant recipients from lower-income countries seems as good as graft survival among all (low-, medium-, and high-risk) graft recipients from high-income countries.

Amsterdam UMC University of Amsterdam Department of Pediatric Nephrology Emma Children's Academic Medical Center Meibergdreef 9 Amsterdam The Netherlands

Center for Pediatrics Vilnius University Vilnius Lithuania

Department of Medicine Zealand University Hospital Roskilde Denmark

Department of Nephrology Kidney Transplantation and Hypertension The Children's Memorial Health Institute Warsaw Poland

Department of Nephrology P and A Kyriakou Children's Hospital Athens Greece

Department of Paediatric Nephrology Great Ormond Street Hospital for Children NHS Foundation Trust London UK

Department of Paediatrics Queen Silvia Children's Hospital Sahlgrenska University Hospital Gothenburg Sweden

Department of Pediatric Nephrology Akdeniz University Faculty of Medicine Antalya Turkey

Department of Pediatric Nephrology and Transplantation Helsinki University Hospital University of Helsinki Helsinki Finland

Department of Pediatric Nephrology Hospital Pediátrico de Coimbra Coimbra Portugal

Department of Pediatric Nephrology La Paz Children's Hospital Madrid Spain

Department of Pediatric Nephrology University Hospital Antwerp Antwerp Belgium

Department of Pediatric Nephrology University Medical Center Ljubljana Slovenia; Faculty of Medicine University of Ljubljana Slovenia

Department of Pediatrics 1 University Children's Hospital Heidelberg Germany

Department of Pediatrics and Biomedical Center 2nd Faculty of Medicine and Faculty of Medicine in Pilsen Charles University Prague Prague Czech Republic

Department of Pediatrics Belarusian State Medical University Minsk Belarus

Department of Pediatrics Bordeaux University Hospital Bordeaux Population Health Research Center UMR 1219 University of Bordeaux Bordeaux France

Department of Pediatrics Division of Pediatric Nephrology Geneva University Hospital Geneva Switzerland

Department of Pediatrics Faculty of Medicine University of Debrecen Debrecen Hungary

Division of Nephrology Dialysis and Transplantation Department of Pediatrics University Hospital Zagreb Zagreb Croatia

Division of Pediatric Nephrology and Gastroenterology Department of Pediatric and Adolescent Medicine Medical University of Vienna Vienna Austria

Divsion of Pedatrics and Adolescent Medicine Oslo University Hospital Rikshospitalet Norway

ESPN ERA EDTA Registry Amsterdam UMC University of Amsterdam Department of Medical Informatics Amsterdam Public Health Research Institute Meibergdreef 9 Amsterdam The Netherlands

Faculty of Medicine School of Health Sciences University of Iceland Reykjavik Iceland

Nephrology and Hemodialysis Clinic Department of Pediatrics Medical University of Sofia Sofia Bulgaria

Pediatric Department Children's Hospital Comenius University Bratislava Slovakia

Pediatric Nephrology and Dialysis Unit Pediatric Hospital Giovanni XXIII Bari Italy

Pediatric Nephrology Department Université de Paris Hôpital Necker Enfants Malades Assistance Publique Hôpitaux de Paris Paris France

University Children's Hospital Nephrology and Urology Departments Belgrade Serbia; Medical Faculty University of Belgrade Belgrade Serbia

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