Highly sensitized pediatric kidney candidates have reduced access to kidney transplant in the United States.

Kidney transplantation is prioritized for children in the United States, yet equity for highly sensitized pediatric candidates remains uncertain. Using Organ Procurement and Transplantation Network data, we examined kidney-only candidates aged 0 to 17 years listed between December 4, 2014, and December 31, 2024, who were ever activated, comparing the Kidney Allocation System (KAS; Era 1) and the 2021 circle-based revision (KAS250; Era 2). Candidates were stratified by calculated panel-reactive antibody (cPRA) at first activation (0%-20%, 21%-79%, 80%-99%, 100%). The primary outcome was the 3-year cumulative incidence of deceased-donor kidney transplant (DDKT) in competing-risk analysis. Among 7215 activated pediatric candidates, highly sensitized candidates accepted organs from greater distances. In both eras, candidates with cPRA 80% to 99% (Era 1: subdistribution hazard ratio [SHR] 0.46, 95%CI 0.36-0.59; Era 2: SHR 0.53, 95%CI 0.42-0.67) and cPRA 100% (Era 1: SHR 0.28, 95%CI 0.16-0.48; Era 2: SHR 0.28, 95%CI 0.18-0.43) had persistently reduced access to DDKT (all P < .001). While nonsensitized candidates had higher DDKT rates than adults, those with cPRA 80% to 99% or 100% had similar rates to adults. Findings suggest that pediatric prioritization does not fully extend to highly sensitized children, supporting the need for broader sharing.