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What is the role for mycophenolate mofetil in pediatric renal transplantation?
1Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. aneu@jhmi.edu
Abstract:
Mycophenolate mofetil (MMF) has gained considerable popularity in pediatric renal transplantation. This popularity is largely a result of data from three large trials of MMF in adult cadaveric transplant patients who demonstrated a decreased rate of acute rejection episodes when treated with cyclosporin A (CsA), prednisone, and MMF compared with those receiving CsA, prednisone, and azathioprine (AZA) or placebo. However, the ability of MMF to reduce acute rejection appears to be limited to the first month post-transplant, and its effectiveness with microemulsion CsA or tacrolimus-based regimens has not been proven. In addition, there are currently no data that convincingly demonstrate that this agent improves graft survival, patient survival, graft function or protects against chronic rejection. Finally, there may be an increased risk for severe cytomegalovirus (CMV) disease and lymphoproliferative disorder with central nervous system involvement in patients treated with MMF. These data call into question the role of MMF in current immunosuppressive regimens.
Insights
Mycophenolate mofetil (MMF) shows promise in reducing early acute rejection in pediatric kidney transplants. However, its long-term benefits and risks, including cytomegalovirus disease, require further investigation.
Area of Science:
- Nephrology
- Immunosuppression
- Transplantation
Background:
- Mycophenolate mofetil (MMF) is increasingly used in pediatric renal transplantation.
- Its popularity stems from adult trials showing reduced acute rejection with cyclosporine A (CsA), prednisone, and MMF versus azathioprine (AZA).
Purpose of the Study:
- To evaluate the efficacy and safety of MMF in pediatric renal transplantation.
- To assess MMF's impact on acute rejection, graft survival, patient survival, graft function, and chronic rejection.
Main Methods:
- Review of data from three large trials in adult cadaveric transplant patients.
- Comparison of MMF-based immunosuppression with CsA, prednisone, and AZA or placebo.
Main Results:
- MMF reduced acute rejection in the first month post-transplant in adult trials.
- Effectiveness with microemulsion CsA or tacrolimus is unproven.
- No convincing data on improved graft/patient survival, function, or protection against chronic rejection.
- Potential increased risk of severe cytomegalovirus (CMV) disease and CNS lymphoproliferative disorder.
Conclusions:
- The role of MMF in pediatric renal transplantation requires further evaluation.
- Current data do not support its use for long-term benefits or protection against chronic rejection.
- Potential risks associated with MMF warrant careful consideration in immunosuppressive regimens.