The American Society of Transplantation

I don’t believe that there is any one immunosuppression protocol that would be considered a “state of the art”. As with any other organ transplant and age group, many combinations are utilized currently. Most programs in the USA use some form of induction for children receiving a kidney transplant. The induction agent varies widely; rabbit anti-thymocyte globulin and basiliximab are probably most common, with very specialized centers using alemtuzumab (source UNOS database; www.unos.org). More than 80% of centers use tacrolimus and more than 90% use mycophenolate as part of maintenance immunosuppression in new transplants. Steroid use has dropped considerably, probably only 50-60% of new transplants now receive (source: NAPRTCS database; www.naprtcs.org). Anti-infective prophylaxis has become increasingly important, given the emergence of infections as an equal or bigger problem than acute rejection (1). Most centers will use some form of anti-fungal prophylaxis (nystatin or clotrimazole) for 3 months, anti-bacterial prophylaxis for 3-6 months (also covers pneumocystis) and anti-viral prophylaxis (typically valganciclovir) for 3-12 months. See the recently published KDIGO guidelines for recommendations (2). Published protocols are from specific research centers such as Pittsburgh and Stanford (3-6); they represent specialized protocols unique to those centers or consortia, not necessarily what the majority of centers currently do. 1. Dharnidharka VR, Stablein DM, Harmon WE. Post-transplant infections now exceed acute rejection as cause for hospitalization: a report of the NAPRTCS. Am J Transplant. 2004 Mar;4(3):384-9. 2. Chapman JR. The KDIGO clinical practice guidelines for the care of kidney transplant recipients. Transplantation. Mar 27;89(6):644-5. 3. Li L, Chang A, Naesens M, Kambham N, Waskerwitz J, Martin J, et al. Steroid-free immunosuppression since 1999: 129 pediatric renal transplants with sustained graft and patient benefits. Am J Transplant. 2009 Jun;9(6):1362-72. 4. Tan HP, Donaldson J, Ellis D, Moritz ML, Basu A, Morgan C, et al. Pediatric living donor kidney transplantation under alemtuzumab pretreatment and tacrolimus monotherapy: 4-year experience. Transplantation. 2008 Dec 27;86(12):1725-31. 5. Harmon W, Meyers K, Ingelfinger J, McDonald R, McIntosh M, Ho M, et al. Safety and efficacy of a calcineurin inhibitor avoidance regimen in pediatric renal transplantation. J Am Soc Nephrol. 2006 Jun;17(6):1735-45. 6. Benfield MR, Bartosh S, Ikle D, Warshaw B, Bridges N, Morrison Y, et al. A randomized double-blind, placebo controlled trial of steroid withdrawal after pediatric renal transplantation. Am J Transplant. Jan;10(1):81-8.