PEDIATRIC RENAL TRANSPLANTATION UNDER TACROLIMUS-BASED IMMUNOSUPPRESSION

Abstract

21 Between December 14, 1989, and December 31, 1996, 82 pediatric renal transplantations alone were performed under tacrolimus-based immunosuppression without induction antilymphocyte antibody therapy. Patients undergoing concomitant or prior liver and/or intestinal transplantation were not included in the analysis. The mean recipients age was 10.6±5.2 years (range 0.7-17.9). 18(22%) cases were retransplantations, and 7(9%) were in patients with panel reactive antibody levels over 40%. 34(41%) cases were with living donors, and 48(59%) were with cadaveric donors. The mean donor age was 27.3±14.6 years (range 0.7-50), and the mean cold ischemia time in the cadaveric cases was 26.5±8.8 hours. The mean number of HLA matches and mismatches was 2.8±1.2 and 2.9±1.3; there were 5 (6%) O-Ag mismatches. The mean follow-up was 4.0±0.2 years. The 1 and 4 year actuarial patient survival was 99% and 94%. The 1 and 4 year actuarial graft survival was 98% and 84%. The mean serum creatinine was 1.1±0.5 mg/dl, and the corresponding calculated creatinine clearance was 88±25 ml/min/1.73m2. 66% of successfully transplanted patients were withdrawn from prednisone. In children off steroids, the mean standard deviation height scores (Z-score) at the time of transplantation and at 1 and 4 years were -2.3±2.0, -1.7±1.0, and +0.36±1.5. 86% of successfully transplanted patients were not taking anti-hypertensive medications. The incidence of acute rejection was 44%; between 12/89 and 12/93, it was 63%, and between 1/94 and 12/96, it was 23% (p=0.0003). The incidence of steroid-resistant rejection was 5%. The incidence of delayed graft function was 5%, and 2% of patients required dialysis within one week of transplantation. The incidence of cytomegalovirus was 13%; between 12/89 and 12/92, it was 17%, and between 1/93 and 12/96, it was 12%. The incidence of early EBV-related PTLD was 9%; between 12/89 and 12/92, it was 17% and between 1/93 and 12/96, it was 4%. All of the early PTLD cases were treated successfully with temporary cessation of immunosuppressive and antiviral therapy without patient or graft loss. These data demonstrate the short- and medium-term efficacy of tacrolimus-based immunosuppression in pediatric renal transplant recipients, with reasonable patient and graft survival, routine achievement of steroid and anti-hypertensive medication withdrawal, gratifying increases in growth, and, with further experience, a decreasing incidence of both rejection and PTLD.