Improved Patient- and Graft-Survival with Mostly Normal Final Height 20 Years after Pe-diatric Renal Transplant without Steroids

Introduction: Growth retardation and reduced final height remain a unsolved problem in children after renal transplantation (RTx). Apart from chronic renal failure the use of steroids (S) is a major etiological factor. We report on a pediatric renal transplant population, who received mainly a S-free immunosuppression (Is). We compared the results with a review concerning frequency of acute rejection episodes, patient- and graft survival and growth without S after transplantation.Patients and methods: Between 1981 and 2001 106 RTx (5 live-related) were performed in 92 children (55m/37f, 55 prepuberal/ 37 puberal) aged 1.7-20.0 years (median 10.1). Mean follow-up was 8.1 + 5.3 yrs. Is was started with: 1. CyA 130 mg/m2/d i.v. or Tac 0.03 mg/kg/d (since 10.97) i.v. for 3 days. Target trough levels were 200 ng/ml or 12 ng/ml respectively, 2. Aza 3 mg/kg/d or MMF 1.2g/m2/d (since 10/97) and 3. S initially 60 mg/m2/d i.v. It was tapered weekly in steps of 50% until 5 mg were achieved, thereafter in steps of 1mg every 3 weeks. S was stopped in 46 prepuberal- and 28 puberal children (80%). In 19/106 S could not be stopped (7/19 had early thrombosis).Results: In the 1. year after RTx acute rejection episodes (ARE) occurred in 43% of all (in 53% with CyA, in 7% with CyA/MMF or Tac (n=14)), in grafts without S in 37.8% and at 7 with S in 100%. After finishing S ARE occurred in 29%. The First-graft survival at 5,10 and 20 yrs was 79, 59 and 35%. It was without S in the 1. decade (3/81-2/91) at 5 und 10 years 76,7 und 53,1% and improved in the 2. decade (3/91-2/01) to 91.7% 5 und 10 yrs (to 81,7% with early thrombosis). The patient survival at 10 and 20 years was 100% and 98.9%.In the first year after RTx growth velocity of 46 prepuberal transplanted children increased to 8.9 + 1.9 cm/year (2.8 SD). Catch-up growth occurred until 6 years after RTx. The SD of height increased from –2.4 to –0.6. 17 out of 46 prepuberal transplanted children reached final height at –0.6 SD with a mean creatinine of 1.9 mg/dl.Conclusions: A long-term Is without S was possible in >80% of children. It allows catch-up growth, normal final height and better rehabilitationt and a better rehabilitation. Patient and graft survival were excellent, especially in S-free therapy. S-maintenance therapy is not justified in the rule.