*Purpose: Medication non-adherence continues to particularly affect adolescent kidney transplant recipients. Standard immunosuppressive regimen at our center includes tacrolimus, and mycophenolate with or without steroids. Despite the availability of once daily extended release (ER) Tacrolimus, a once daily anti-metabolite option was traditionally not available, thus necessitating patients to take twice daily mycophenolate. We trialed patients on a once daily regimen of Tacrolimus ER, Delayed Release Mycophenolate (Myfortic®), dosed at 600mg/m2 once daily with or without prednisone. Once daily immunosuppressive regimen administered all together at a convenient time in the day will potentially improve adherence and thereby prolong graft survival.

*Methods: This is a retrospective chart review of all patients placed on once daily regimen as described above. We evaluated the cohort for rejection, de-novo donor specific antibody development, graft function, mycophenolate toxicity, infection, and graft loss.

*Results: A total of 16 patients were included who had history suggestive of immunosuppression non-adherence and were converted from twice daily to once daily regimen; 6/16 were steroid-based. 8/16 patients presented with biopsy proven acute cellular rejection (ACR), 4 patients had antibody mediated rejection (AMR) along with ACR with development of new DSAs, thought to be secondary to immunosuppression non-adherence. Age range was 14-22 years, 10 patients were female. The first patient initiated on this regimen was in Jan 2019, the follow up period was at least 3 months for all patients. No new ACR since this change, apart from 2 patients who had incomplete resolution of previous ACR requiring further anti-rejection therapy. One patient developed de-novo DSA within 1 month from conversion. GFR (estimated by the CKiD Under 25 GFR equation) remained unchanged, no graft loss. 24 hour trough tacrolimus and mycophenolate levels did not change (Figure 1). Median mycophenolate trough level at 3 months remained >3 μg/ml. There were no viral nor other infections, with no evidence of neutropenia. The regimen was well tolerated with no report of gastrointestinal or other side effects.

*Conclusions: Once daily delayed release mycophenolate (Myfortic®) dosing is well tolerated, generally mounts a good blood MMF level and offers patients the ability for a full once per day immunosuppression regimen ultimately improving adherence without increase the risk of graft loss. The safety and efficacy of this regimen should be studied in a large scale randomized controlled study.

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