Holding On or Letting Go: Immunosuppression After Pediatric Kidney Allograft Failure

Kidney allograft failure is a devastating event often marked by return to dialysis and is associated with increased morbidity and mortality. Given the young age at transplant for pediatric recipients, they are likely to require retransplantation during their lifetime. Optimal immunosuppression (IS) management in the setting of a failing allograft is crucial to preserve residual renal function, prevent graft intolerance, and limit the development of anti-HLA antibodies. The management of IS during allograft failure is highly variable between providers and reflects the paucity of data to guide clinical decision-making. In addition, pediatric recipients have shorter waiting times for kidney transplants due to priority allocation for deceased donors compared to adult candidates, suggesting that current protocols may not be generalizable to pediatric kidney recipients with allograft failure. In this review we summarize the extent of current recommendations, identify limitations as they pertain to pediatric patients, and provide recommendations for vitally needed future research.