*Purpose: The purpose of this study was to evaluate the efficacy of an immunosuppression protocol change, which included avoidance of anti-thymocyte globulin for induction and decreased mycophenolate dosing, on the incidence of EBV viremia and PTLD in high-risk pediatric kidney transplant recipients from a single center.

*Methods: This was a retrospective chart review of pediatric patients age 18 years or younger who underwent kidney transplantation between January 1, 2008, and December 31, 2017. Our institution implemented a new immunosuppression protocol in 2011 only for pediatric EBV mismatched patients that avoided anti-thymocyte globulin during induction in favor of basiliximab, and decreased initial mycophenolate dosing from 600 mg/m²/dose to 300 mg/m²/dose twice daily. Patients were grouped and analyzed according to the old versus new protocol. The examined variables included: living versus deceased donor, EBV status of donor and recipient, anti-thymocyte globulin versus basiliximab at induction, mycophenolate dosage, incidence of EBV viremia, incidence of lymphoma, graft loss, and patient survival.

*Results: There were 111 patients that met the initial inclusion criteria. There were 46 EBV mismatched transplants studied, 12 following the old protocol and 34 following the new protocol. The protocol was changed only in the patients with EBV mismatch. The incidence of EBV viremia prior to the protocol change in the EBV mismatched group was 66.7% compared to 16% in the EBV non-mismatch group. None of the EBV non-mismatched patients developed PTLD during the study time period. In the EBV mismatched group, the incidence of EBV viremia was significantly reduced from 66.7% to 32.4% (p=0.049) after the change in immunosuppression protocol. The incidence of PTLD also significantly decreased from 25% to 2.9% (p=0.049) after the change in immunosuppression protocol in the EBV mismatched population. There was no significant change in graft survival or patient survival after the protocol change.

*Conclusions: Our protocol change, which included avoiding anti-thymocyte globulin during induction in favor of basiliximab, and decreased mycophenolate dosing, significantly reduced the incidence of EBV viremia and PTLD in our EBV mismatched pediatric kidney transplant recipients. In addition, this immunosuppression reduction did not result in a significant decrease in graft or patient survival. The incidence of EBV viremia was lower in our EBV non-mismatch groups and none developed PTLD.

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