*Purpose: To explore adherence and long-term impacts of a sirolimus-based, low-dose calcineurin inhibitor regimen with early steroid withdrawal in pediatric renal transplant recipients.

*Methods: A single-center, retrospective case series focusing on patient and graft survival, medication adherence, rejection rates and incidence of adverse events. Thirteen pediatric renal transplant cases from 2004-2020 managed with an early-steroid withdrawal immunosuppressive combination including low-dose tacrolimus, low-dose mycophenolate mofetil and low-dose sirolimus were included as were seven cases on a traditional steroid-maintenance regimen.

*Results: Twenty total patients received renal transplant at ages between 9 and 17. 31% of the novel regimen experienced graft failure (75% non-adherence; 50% chronic rejection) relative to 57% in the steroid group (75% non-adherence; 100% chronic rejection). Overall, 54% of novel arm patients reported non-adherence compared to 71% in the steroid arm. New-onset adverse events including hypertension (57% vs 43%), viral infection (38% vs 14%), and malignancy (15% vs 0%) occurred more frequently on novel immunosuppression rather than steroid maintenance. However, weight gain (46% vs 86%) occurred less commonly whereas hyperlipidemia (31% vs 29%) and diabetes mellitus (15% vs 14%) were relatively consistent between groups.

*Conclusions: Traditional anti-rejection agents (e.g., calcineurin inhibitors, glucocorticoids) present significant risks in pediatric populations (Tonshoff & Hocker, 2006; Tredger, Brown & Dhawan, 2008; Fehrenbach et al., 2019). By contrast, calcineurin inhibitor avoidance with the use of mTOR inhibitors yields similar graft outcomes with more favorable side effect profiles (Roque et al., 2008). Less adverse events may result in more consistent adherence (Dobbels et al., 2010). However, there remains a lack of comprehensive understanding of downstream impacts of these alternatives in children. Despite proven success in adult populations, our findings suggest significant complications and improved but nonetheless continued non-adherence in pediatric transplants despite glucocorticoid and calcineurin inhibitor avoidance (Conti, Petrov, Elbalhoul & Gallichio, 2008; Lopez-Soler et al., 2017). It follows that more concerted efforts to understand and address non-adherence, as well as continued focus on adverse events that remain present regardless of compliance, are necessary to optimize the outlook for pediatric renal transplant patients.

« Back to 2022 American Transplant Congress