Why Do Adolescents and Young Adults Continue to Have the Worst Kidney Transplant Outcomes?

Adolescents and young adults (AYA) continue to experience the highest rates of kidney allograft failure despite major advances in transplantation medicine and the widespread implementation of transition programs designed to support transfer from pediatric- to adult-centered care. This editorial examines the contemporary findings reported by Marroquin et al. from the United States Renal Data System (USRDS) and places these observations within the broader context of developmental medicine, transition science, transplant immunology, and emerging adulthood. Recent USRDS data demonstrate that adolescents and young adults remain at substantially increased risk of early graft loss compared with older adult recipients, even after adjustment for donor quality, socioeconomic factors, insurance status, sensitization, and comorbidities. While nonadherence remains an important contributor, accumulating evidence suggests that excess risk may also reflect developmental, psychosocial, structural, and potentially biological vulnerabilities unique to adolescence and emerging adulthood. These include challenges related to autonomy acquisition, educational and financial instability, mental health, neurocognitive burden, changing family support structures, healthcare-system fragmentation, and age-related immunologic factors. Persistent excess graft loss among AYA kidney transplant recipients suggests that current transition frameworks may insufficiently address the developmental realities of emerging adulthood. Future models should move beyond transfer of medical responsibility alone and emphasize longitudinal developmental support that integrates pediatric and adult transplant services, psychosocial care, mental health resources, and structured autonomy development. Such approaches may improve long-term graft survival, quality of life, and healthcare sustainability.