The
calcineurin inhibitors,
cyclosporine (
ciclosporin) [microemulsion] and
tacrolimus, are the principal
immunosuppressants prescribed for adult and pediatric
renal transplantation. For pediatric patients, both drugs should be dosed per body surface area, and pharmacokinetic monitoring is mandatory. While monitoring of the trough levels may suffice for
tacrolimus,
cyclosporine therapy that utilizes the microemulsion formulation requires additional monitoring (e.g. determination of 2-hour post-dose levels). In a well designed randomized study in children, as in studies in adults, there was no difference in short-term patient and graft survival with
cyclosporine microemulsion and
tacrolimus. However,
tacrolimus was significantly more effective than
cyclosporine microemulsion in preventing acute rejection after
renal transplantation when used in conjunction with
azathioprine and
corticosteroids. With regard to long-term outcome, the difference in acute rejection episodes resulted in a better glomerular filtration rate at 1 year after
transplantation and eventually in better graft survival 4 years after
renal transplantation. Whether this difference persists when
calcineurin inhibitors are used in combination with
mycophenolate mofetil has not been determined. The prevalence of hypomagnesemia was higher in the
tacrolimus group whereas
hypertrichosis and
gingival hyperplasia occurred more frequently in the
cyclosporine group. In contrast with adults, the incidence of post-
transplantation diabetes mellitus was not significantly different between
tacrolimus- and
cyclosporine-treated patients. There was also no difference with regard to post-
transplantation lymphoproliferative disorder. Medication costs were similar, but in view of the lower rejection episodes and better long-term graft survival as well as the more favorable cosmetic side effect profile,
tacrolimus may be preferable. The recommendation drawn from the available data is that both
cyclosporine and
tacrolimus can be used safely and effectively in children. We recommend that
cyclosporine should be chosen when patients experience
tacrolimus-related adverse events.