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Kidney transplantation is a preferable treatment of children with end-stage kidney disease. All kidney
transplant recipients, including pediatric need immunosuppressive medications to prevent rejection episodes and
graft loss.
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Induction therapy is used temporarily only immediately following transplantation while maintenance immunosuppressive
drugs are started and given long-term. There is currently no consensus regarding the use of induction
therapy in children; its use should be decided based on the immunological risk of the child.
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The recent progress shows that the recommended strategy is to use as maintenance immunosuppressive therapy a
combination of a calcineurin inhibitor (preferably tacrolimus) with an antiproliferative drug (preferably mycophenolate
mofetil) with steroids that can be withdrawn early or late in low-risk children. The mTOR-inhibitors
(sirolimus, everolimus) are used rarely in pediatrics because of common side effects and no evidence of a benefit
over calcineurin inhibitors. The use of calcineurin inhibitors, mycophenolate, and mTOR-inhibitors should be
followed by therapeutic drug monitoring.
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Immunosuppressive therapy of acute rejection consists of high-dose steroids and/or anti-lymphocyte antibodies
(T-cell mediated rejection) or plasma exchange, intravenous immunoglobulines and/or rituximab (antibodymediated
rejection).
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The future strategies for research are mainly precise characterisation of children needing induction therapy, more
specific indications for mTOR-inhibitors and for the far future, the possibility to reach the immuno tolerance.
Pre-Transplant Donor-Specific T-Cell Alloreactivity Is Strongly Associated with Early Acute Cellular Rejection in Kidney Transplant Recipients Not Receiving T-Cell Depleting Induction Therapy