Trading one disease for another

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Patient and graft survival have increased in pediatric liver transplant recipients to unprecedented levels among solid organ transplant recipients. The long-term consequences of immunosuppressive therapy, therefore, take on more important meaning in determining overall outcome. Calcineurin inhibitors, the mainstay for 25 years, have been found to cause significant nephrotoxicity in adults and children, but other factors associated with loss of glomerular filtration rate (GFR) have not been carefully determined. Utilizing techniques to directly measure GFR, rather than the inaccurate calculated GFR, Campbell et al demonstrate renal dysfunction in a worrisome 32% of pediatric liver transplant recipients, with the duration of immunosuppression, the measured GFR at one year after transplant, and the use of cyclosporine compared to tacrolimus strongly associated with renal dysfunction. Thus, long life in children receiving liver transplants is not without its hazards, stressing the need to better understand current immunosuppressive agents and to develop safer long-term agents and immunosuppression regimens.