Résumé
Background and objectives: the management of immunosuppressive therapies (IS) after allograft failure (AF) in the pediatric population remains uncertain, involving a delicate balance between the benefits of continuing IS to reduce the risk of sensitization impeding access to future transplantation and the risks associated with prolonged IS. The aim of this study was to investigate the relationship between IS management, sensitization, and consequences on access to a second transplantation in these patients.Study design: we conducted a nationwide multicenter retrospective study in pediatric patients with kidney AF before age of 18, between January 2006 and December 2020. Demographic characteristics, IS related events, complications following AF and time to retransplantation were collected. Patients were divided into two groups according to whether they had stopped IS within less than 12 months after AF "IS discontinuation" group or continued IS more than one year after AF "IS maintenance" group. Sensitization was assessed by analyzing changes in calculated panel reactive antibody (cPRA) between return to dialysis time (Early cPRA) and 6 months after discontinuation of IS, or 12 months after AF if IS was continued (Late cPRA).Results: 72 patients were included, of whom 35 discontinued IS within one year after AF. Late cPRA was significantly higher in the "IS discontinuation" group than in the "IS maintenance" group (respectively 88.7%±18.8 and 58.9±40.3, p<0.001). The occurrence of allograft nephrectomy and IS discontinuation were both independent risk factors for sensitization. On the other hand, continuation of IS and more specifically the use of a calcineurin inhibitor was associated with a lower risk of immunization. The waiting time for retransplantation was doubled in patients who discontinued IS. However, the rate of infectious and hematological complications was comparable between the two groups.Conclusion: discontinuation of IS after AF in pediatric kidney transplant patients is associated with a significant increased risk in sensitization, which has a negative impact in the likelihood to access to retransplantation. These findings support the continuation of IS therapies, especially calcineurin inhibitors, at least more than one year after AF.