Cyclosporine microemulsion (CyA) and
tacrolimus (Tac) are the principal
immunosuppressants prescribed for adult and pediatric
renal transplantation. In the majority of patients, these
calcineurin inhibitors have been used in combination with other immunosuppressive drugs, such as
azathioprine or
mycophenolate mofetil (MMF). In this review we will address the question of what
calcineurin inhibitor we should use in an individual pediatric renal transplant patient. Well-designed randomized studies in children showed no difference in short-term patient and graft survival with
cyclosporine microemulsion and
tacrolimus. However Tac is significantly more effective than CyA microemulsion in preventing acute rejection after
renal transplantation in a pediatric population when used in conjunction with
azathioprine and
corticosteroids. This difference disappears when
calcineurin inhibitors are used in combination with MMF as both Tac and CyA produce similar rejection rates and graft survival. However, Tac is associated with improved graft function at 1 and 2 yr post-transplant. Adverse events of hypomagnesaemia and
diarrhea seem to be higher in Tac group whereas
hypertrichosis, flu syndrome and gum
hyperplasia occurs more frequently in the CyA group. The incidence of post-transplant
diabetes mellitus was almost identical between Tac and CyA treated patients. The recommendation drawn from the available data is that both CyA and Tac can be used safely and effectively in children. However Tac may be preferable to CyA because of
steroid sparing effect and less
hirsutism. We recommend that
cyclosporine should be chosen when patients experience Tac-related adverse events. Nevertheless, the best
calcineurin inhibitor should be decided on individual patients according to variable risk factors, such as risk of rejection in sensitized patient or
delayed graft function. The possibility of adverse events should also be considered.