The potential for tolerance in pediatric renal transplantation

Immune tolerance has remained the Holy Grail in transplantation since the first kidney transplantation was performed over 50 years ago. Children present unique challenges in renal transplantation because of increased infectious risks and adolescent nonadherence to the intensive medication regimen necessary for allograft function. The current review presents recent studies and approaches toward achieving tolerance in renal transplantation and the prospects for pediatric patients.

A number of approaches have been used toward minimization of immunosuppression in pediatric patients, but none has yet achieved true operational tolerance with maintenance of allograft function of all immunosuppression. Recent work in adult renal transplant recipients using combined kidney-bone marrow transplantation by the induction of transient mixed chimerism has allowed for full withdrawal of immunosuppression with stable long-term renal function.

On the basis of recent adult studies, the prospect of immune tolerance in pediatric renal transplantation remains hopeful and may be ready for extension to the adolescent population.