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Temporary mycophenolate discontinuation and reintroduction in pediatric kidney transplantation: predictors and
Moran Plonsky Toder1,2, Shirley Pollack3,4, Rami Tibi4
1Technion - Israel Institute of Technology, The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel. m.plonsky@technion.ac.il.
Background:
Temporary discontinuation of mycophenolate mofetil (MMF) is frequently required in pediatric kidney transplant recipients, most often in response to viral complications. However, data regarding the long-term safety of MMF discontinuation, feasibility of reintroduction, and predictors of the need for MMF withdrawal in children remain limited.
Methods:
We conducted a retrospective, single-center cohort study of pediatric kidney transplant recipients with longitudinal follow-up. Clinical, virologic, immunologic, and transplant-related data were collected. Outcomes included longitudinal estimated glomerular filtration rate (eGFR), biopsy-proven acute rejection, graft loss, de novo donor-specific antibody (dnDSA) development, unplanned hospitalization, and MMF reintroduction. Factors associated with MMF discontinuation were evaluated using multivariable regression analysis.
Results:
Among 65 pediatric kidney transplant recipients, 22 (33.8%) required temporary MMF discontinuation, most commonly within the first post-transplant year. Opportunistic viral infections accounted for the majority of MMF withdrawal events, with BK virus as the predominant indication. MMF reintroduction was feasible in most patients (15/22). Longitudinal eGFR trajectories, rates of rejection, graft loss, dnDSA development, and unplanned hospitalization did not differ between patients who discontinued MMF and those who maintained full therapy. Younger age at transplantation emerged as the sole independent predictor of the need for MMF discontinuation.
Conclusions:
In this real-world pediatric cohort, temporary MMF discontinuation, when clinically indicated, closely monitored, and followed by cautious reintroduction, was not associated with adverse long-term graft outcomes. Younger age at transplantation was associated with a higher likelihood of MMF discontinuation, supporting individualized immunosuppression strategies and proactive efforts to identify children at risk for viral-driven immunosuppression intolerance.
Insights
Temporary mycophenolate mofetil discontinuation in pediatric kidney transplants is safe long-term, especially when monitored. Younger recipients are more likely to need MMF withdrawal due to viral infections.
Area of Science:
- Pediatric Nephrology
- Transplant Immunology
- Immunosuppression Therapy
Background:
- Temporary discontinuation of mycophenolate mofetil (MMF) is common in pediatric kidney transplant recipients, often due to viral infections.
- Limited data exists on the long-term safety, reintroduction feasibility, and predictors of MMF withdrawal in children.
Purpose of the Study:
- To evaluate the long-term safety and graft outcomes associated with temporary MMF discontinuation in pediatric kidney transplant recipients.
- To assess the feasibility of MMF reintroduction after withdrawal.
- To identify predictors for the need for MMF discontinuation.
Main Methods:
- Retrospective, single-center cohort study of pediatric kidney transplant recipients.
- Collected clinical, virologic, immunologic, and transplant-related data.
- Analyzed longitudinal outcomes including eGFR, rejection, graft loss, dnDSA, hospitalization, and MMF reintroduction. Multivariable regression identified factors associated with MMF discontinuation.
Main Results:
- 22 out of 65 (33.8%) pediatric kidney transplant recipients required temporary MMF discontinuation, primarily within the first post-transplant year, often due to BK virus infections.
- MMF reintroduction was successful in most cases (15/22).
- No significant differences in eGFR, rejection rates, graft loss, dnDSA development, or hospitalizations were observed between patients who discontinued MMF and those who did not. Younger age at transplantation was the only independent predictor for MMF discontinuation.
Conclusions:
- Temporary MMF discontinuation, when clinically indicated and closely monitored in pediatric kidney transplant recipients, is not associated with adverse long-term graft outcomes.
- Younger age at transplantation is a significant predictor for MMF discontinuation, highlighting the need for individualized immunosuppression strategies and proactive monitoring for viral complications.
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