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Outcomes (acute rejection and graft loss) in steroid-based and steroid-avoidance protocols were assessed in 4627 children who received tacrolimus and mycophenolate immunosuppression and did not have multiorgan transplants. Compared to steroid-based protocols, steroid avoidance was associated with decreased risk of acute rejection at 6 months posttransplant (8.3% vs. 10.9%, p?= 0.02) and improved 5-year graft survival (84% vs. 78%, p? http://www.selleckchem.com/products/MG132.html acute rejection at 6 months, but this no longer reached statistical significance, http://www.selleck.cn/products/pfi-2.html and there was no association of steroid avoidance with graft loss. We conclude that, in clinical practice, steroid avoidance appears safe with regard to graft rejection and loss in pediatric kidney transplant recipients at lower immunologic risk. Steroids have traditionally played a central role in immunosuppression for pediatric kidney transplant recipients, preventing T cell activation and thereby protecting allografts from immune-mediated damage (1). Harmful sequelae of prolonged steroid therapy are well known and include cataracts, diabetes, hypertension, infection and cardiovascular morbidity (2). Furthermore, of particular importance in the pediatric population is the growth-suppressive effect of long-term steroid exposure (3,4). Recently, there has been an increasing interest in the development of posttransplant immunosuppression protocols which limit or avoid exposure to steroids in order to minimize these undesired side effects. Several trials of complete steroid avoidance (5�C9) or early steroid withdrawal (10�C12) in pediatric patients have been http://www.selleckchem.com/products/epacadostat-incb024360.html published with encouraging results, with graft survival and incidence of acute rejection similar to steroid-based protocols. These studies, however, have been mostly limited to single center experiences. Furthermore, only historical controls (often treated prior to the routine use tacrolimus and mycophenolate) were used for comparison. We sought to more comprehensively investigate the effect of steroid avoidance on graft outcomes by using data collected by the United Network for Organ Sharing (UNOS) on all pediatric kidney transplant recipients from 2002 to 2009, an era characterized by the predominant use of tacrolimus and mycophenolate as integral parts of maintenance immunosuppression. Our primary aims were to evaluate the association of steroid-avoidance protocols with graft survival and development of acute rejection within 6 months of transplant.