Objectives: Kidney transplant is the preferred treatment for end-stage renal disease in children due to superior effects on survival, growth, and quality of life versus dialysis. However, childhood kidney transplant presents unique challenges for long-term social, academic, and professional integration as recipients transition into adulthood. We assessed the educational attainment, employment status, and marital outcomes of an adult cohort of childhood kidney transplant recipients.
Materials and Methods: We retrospectively reviewed all pediatric kidney transplants at Başkent University Hospital from January 2015 through December 2024. Eligibility was defined as a renal graft before the age of 18 years with subsequent follow-up into adulthood. Data were collected via a structured, voluntary questionnaire administered during telephone interviews, which captured academic qualifications, employment status, marital status, posttransplant caregiver arrangements, and demographic information of patients’ parents, including education and employment.
Results: We included 98 patients (mean age, 25.98 ± 5.58 years; mean age at transplant, 14.12 ± 3.83 years), comprising 53 male (54.1%) and 45 female participants (45.9%). Living-related donors were predominant. Regarding the recipients’ parents, maternal education was predominantly low, and 82.7% of the maternal parents were homemakers. Paternal parents demonstrated higher employment rates (n = 47; 48.0%) and more varied educational attainment. Educational attainment revealed that 48 patients (49.0%) completed high school, 15 (15.3%) attended university, and 9 (9.2%) earned a bachelor-level degree. Employment status was reported by 47 recipients (47.9%), with 48 (46.9%) unemployed and 3 (3.1%) employed part time. Seventeen participants (17.3%) were married with at least 1 child.
Conclusions: Pediatric kidney transplant recipients encounter substantial future challenges in social and professional integration as they progress through adulthood. Our cohort demonstrated moderate educational achievement and employment rates, and most were unmarried. Our findings emphasize the importance of long-term multidisciplinary support to promote successful transitions into adulthood, addressing not only medical needs but also social and occupational needs.

Key words : Adulthood, Education, Employment, Pediatric kidney transplantation, Social outcomes

Introduction
Kidney transplant (KT) is the treatment of choice for children with end-stage renal disease. Compared with chronic dialysis, KT offers superior survival, improved growth and neurocognitive development, and better health-related quality of life. Advances in surgical techniques, immunosuppression regimens, infection prophylaxis, and long-term follow-up strategies have led to substantial improvements in graft survival and patient survival during the past decades. Consequently, an increasing number of pediatric KT recipients now survive well into adulthood, shifting the focus of care from short-term graft outcomes to long-term psychosocial, educational, and professional trajectories.^1,2 Despite medical advances, childhood-onset chronic kidney disease (CKD) and subsequent transplant may occur during critical periods of physical, cognitive, and psychosocial development. Early life exposure to uremia, dialysis, hospitalizations, corticosteroid therapy, and associated constraints on academic achievement may adversely affect neurodevelopment, executive functioning, and academic performance. Recent studies published within the past 5 years have emphasized that even in the context of stable graft function, pediatric KT recipients demonstrate higher rates of learning difficulties, delayed academic progression, and lower rates of tertiary education attainment versus age-matched peers in the general population.^1-3 Education attainment is a key determinant of long-term socioeconomic status and employment prospects. Contemporary registry-based and multicenter cohort studies from Europe and North America have reported heterogeneous but consistently lower rates of university completion among adult survivors of pediatric KT compared with national averages.² Academic absenteeism due to medical appointments, fatigue, infections, and hospitalization remains a significant contributor. Moreover, psychosocial factors, including overprotective caregiving patterns, reduced autonomy during adolescence, and challenges during transition from pediatric to adult nephrology services, have been associated with impaired educational continuity.^3,5 Employment outcomes represent another critical dimension of adult integration. In recently published studies, population-based analyses of adults who underwent KT during childhood have shown subsequent adulthood employment rates of approximately 40% to 70%, often lower than matched controls.³ Underemployment and part-time work are also more frequent. Persistent comorbidities, graft dysfunction, fatigue, and concerns regarding workplace discrimination have been identified as impediments to stable employment.³ Beyond academic and professional achievement, social integration (including independent living, partnership formation, and parenthood) is increasingly recognized as a meaningful patient-centered outcome. Emerging studies indicate that adult survivors of pediatric KT are less likely to proceed with marriage or parenthood compared with their peers, although fertility and pregnancy outcomes have improved considerably with modern immunosuppression protocols.^2,3 Delayed psychosocial maturation, chronic health anxiety, and prolonged dependency on family support may contribute to these trends toward social disengagement. At the same time, supportive family environments and higher educational status of recipients’ parents have been associated with more favorable long-term social outcomes, suggesting an interplay between medical, psychological, and socioeconomic determinants.² In this context, our present single-center study aimed to evaluate the long-term social, academic, and professional outcomes of adults who underwent KT during childhood. By examining educational attainment, employment status, and marital outcomes alongside familial characteristics, we sought to contribute region-specific data to the growing body of literature addressing life-course outcomes after pediatric KT and to identify potential targets for intervention during long-term follow-up.

Materials and Methods
We retrospectively reviewed all pediatric patients who underwent KT at Başkent University Hospital for the decade from January 2015 through December 2024. Eligible participants were individuals who received a renal graft before the age of 18 years and subsequently transitioned into adulthood. Among the total of 220 potential participants, 98 recipients were evaluated as 122 patients were lost during follow-up. Descriptive statistical analyses were performed on the eligible participants. Data were collected via a structured, voluntary questionnaire administered during telephone interviews, which captured academic qualifications, employment status, marital status, caregiving arrangements after transplant, and demographic information of the recipients’ parents, including education and employment. This study was approved by the ethics committee of the institution before the study began, and the protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration. Informed consent was obtained from patients or their guardians.

Results
The study cohort included 98 patients (mean age, 25.98 ± 5.58 years; mean age at transplant, 14.12 ± 3.83 years), comprising 53 male (54.1%) and 45 female recipients (45.9%). Living-related donors were predominant, with parents serving as donors in 71 cases (72.5%), followed by other relatives in 12 cases (11.2%) and deceased donors in 16 cases (16.3%) (Table 1). Regarding familial situations, maternal education was predominantly low, with 75.5% having completed only primary school; 82.7% self-identified as homemakers. Paternal parents demonstrated higher employment rates (n = 47; 48.0%) and more varied educational attainment, including 14 university graduates (14.2%). Educational attainment revealed that 52 recipients (53.06%) completed high school, 15 (15.3%) attended university, and 9 (9.2%) earned a bachelor-level degree, whereas 13 recipients (13.24%) had only primary school education or less. Employment was reported by 48 recipients (49.0%), with 46 (46.9%) unemployed and 3 (3.1%) working part time. Marital status showed that 17 recipients (17.3%) were married and had at least 1 child. Graft loss was observed in 13 recipients (13.13%).

Discussion
In this single-center cohort of 98 adults who underwent childhood KT, the long-term social, academic, and professional outcomes revealed modest levels of educational attainment, employment, and marital engagement. Nearly half of the recipients completed high school, only a minority attained university degrees, approximately half were employed, and fewer than 1 in 5 of the recipients were married with children. These observations align with and expand upon patterns reported in recent literature on long-term outcomes following adults who underwent childhood KT, highlighting persistent challenges encountered by this population to transition from medical stability to full societal participation. Educational attainment in our cohort was moderate, with less than one-quarter of participants achieving postsecondary education. Recent analyses of long-term outcomes in pediatric CKD cohorts, including those with transplant recipients, indicate that high school graduation rates can be high, yet completion of higher education remains suboptimal relative to general population benchmarks. In the Chronic Kidney Disease in Children study cohort, 97% of young adults completed high school, but fewer than half of young adults completed 2 or more years of college, and nearly 20% of young adults were unemployed or receiving disability benefits. Lower kidney function and deficits in executive function were predictive of poorer educational achievement, underscoring the interplay between medical and cognitive determinants of academic trajectories.^4,5 Neurocognitive vulnerabilities in pediatric KT populations, including impairments in attention and processing speed, have been increasingly recognized and may partially explain lower tertiary education uptake. Systematic reviews across pediatric organ transplant populations have reported persistent learning difficulties that can affect educational progression, potentially mediated by pretransplant and posttransplant treatment exposures and psychosocial stressors.⁶ Employment outcomes in our study, which showed 49.0% employed and 46.9% unemployed, are broadly consistent with other single-center reports. For example, in a Japanese cohort followed into adulthood, approximately three-quarters of patients older than 20 years reported job employment, although marriage and parenthood remained infrequent.⁷ The lower employment rates observed in several cohorts may reflect a complex array of factors, eg, chronic health concerns, fatigue, recurrent medical appointments, caregiver-imposed constraints, limited vocational guidance, and potential employer biases regarding health status.⁴ Furthermore, comparisons with general population employment rates reveal that pediatric KT recipients, particularly those followed into adulthood, often exhibit underemployment or reliance on disability frameworks.⁵ Social integration, as measured by marital status and parenthood, remains an area of notable divergence from general population trends. In our cohort, only 17.3% of participants were married with children. This is consistent with multinational observations that have shown that adult survivors of pediatric kidney failure have a greater likelihood to remain unmarried, to live alone, and to remain childless versus population controls.² Single-center studies have reported low marriage rates and limited parenthood among adult survivors of pediatric kidney failure, pointing to persistent social limitations despite medical stability. The Swiss Pediatric Renal Registry analysis highlighted that adult survivors were more likely to be unemployed and unpartnered, reinforcing the need to contextualize medical success within broader life course frameworks.^2,7 Parental education and family support have emerged as influential determinants of long-term outcomes. In our cohort, education levels of recipients’ maternal parents were lower and most were homemakers, whereas recipients’ paternal parents had more varied educational backgrounds and employment. This distribution may affect educational support, expectations, and access to resources that facilitate academic and professional development. Prior literature suggested that higher education level of patients’ parents correlates with better educational outcomes in chronically ill populations, likely through enhanced navigation of health care and educational systems.⁵ The findings from our cohort and recent literature underscore the notion that survival alone is an insufficient metric of success in pediatric transplants. Long-term follow-up must integrate structured psychosocial support, targeted cognitive and educational interventions, vocational counseling, and transition programs that begin in adolescence and extend into adult care. The early identification of executive function deficits and a focus on tailored educational support may mitigate academic delays, as suggested by large cohort studies.

Strengths and limitations
Strengths of our study include a decade-spanning cohort and structured, direct data collection on key life outcomes. However, limitations of our study include the retrospective design, potential self-report bias in questionnaire responses, and lack of a control group from the general population or from patients with CKD but no history of transplant. Moreover, cultural and socioeconomic factors specific to our region may limit generalizability.

Conclusions
Consistent with recent literature, our findings highlight that adults who undergo KT in childhood encounter substantial future challenges to achieve academic, professional, and social benchmarks versus their peers in the general population with no history of KT. These outcomes reflect the enduring effects of CKD beyond transplant and emphasize the necessity of holistic, multidisciplinary care pathways that support lifelong development and integration.