We analyzed the results of 165 pediatric cadaver renal transplants performed at the University of California at Los Angeles to identify the factors which are linked to improved allograft survival. Both univariate life-table analysis and the Cox proportional hazard model were used. The use of a sequential immunosuppressive regimen (P less than 0.001) and kidneys from donors of more than 6 years of age (P less than 0.001) were found to be the factors having the most influence on primary graft survival. The sequential regimen was the only factor favorably influencing retransplants. With sequential therapy 1- and 2-year actuarial graft survival rates were 94% and 91% in primary transplants, and 82% and 70% in retransplants. Medication noncompliance exerted a large negative effect on transplant outcome. Of 70 recipients who had been on cyclosporine for at least 6 months, 50% evidenced noncompliance. Sixty-four percent of adolescents were noncompliant. Thirteen percent of the recipients lost their graft because of noncompliance. We conclude that good results can be obtained with cadaver renal transplants in children with a sequential immunosuppressive regimen and the use of kidneys from adolescent and adult donors. Noncompliance is a great barrier to long-term success in pediatric transplantation.

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We analyzed the effects of a steroid avoidance protocol in pediatric renal transplant recipients on calculated CrCl (Schwartz), CMV infection, cholesterol, height Z scores, weight Z scores, and BMI Z scores in a case control trial with contemporaneous controls. From 1999 to 2004, 19 pediatric patients (age 1-20 yr) received transplants without steroids using immunosuppression with tacrolimus, mycophenolate mofetil, and daclizumab. Control patients (n = 30) were matched for length of follow-up (minimum one yr), donor type age, type of immunosuppression, sex, date of transplant, and original disease, and CMV status. Graft survival at one year was 100% in both groups. Mean CrCl of steroid-free vs. control patients were not different at 1 year post-transplant. CMV disease was more prevalent in steroid-treated control group (seven of 30 patients) vs. the steroid free control group (zero of 19). Height delta Z scores at one year were NOT different between groups. Weight and BMI delta Z scores were significantly higher in the control group. Cholesterol levels at one year post-transplant were different in the two groups but NOT ABNORMALLY elevated in either group. At one yr post-transplant, steroid-free immunosuppression with tacrolimus, mycophenolate mofetil and daclizumab provides outcomes that are equivalent or superior to those in contemporaneous control patients receiving steroids.

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