For your child's body to accept a new kidney, the Pediatric Kidney Transplant Program team at Cincinnati Children's will prescribe a combination of immunosuppressant medications.

THESE WILL BE TAKEN EVERY DAY FOR AS LONG AS YOUR CHILD HAS A WORKING KIDNEY TRANSPLANT. TAKING THESE MEDICATIONS AS DIRECTED IS THE MOST IMPORTANT STEP YOU CAN TAKE TO PREVENT REJECTION.

Because these immunosuppressant medications have serious side effects, your doctor will adjust the dosages to protect against rejection without undue risk of complications. The most commonly used immunosuppressants include:

• Prednisone
• Tacrolimus (Prograf)
• Cyclosporine (Neoral)
• Mycophenolate Mofetil (CellCept)
• Imuran (Azathioprine)
• Rapamune (Rapamycin, Sirolimus)

Your child will probably take a combination of three of these drugs.

Prednisone, Prednisolone

Prednisone is a steroid medication given to prevent and treat rejection after transplant. It will be given in higher doses for the first few months and is tapered to a smaller maintenance dose thereafter.

How Prednisone Is Supplied

Prednisone is available in liquid as Prelone (15 mg/5 ml) or in 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, or 50 mg tablets. The tablets can be cut in half if necessary.

Special Instructions

• Never stop prednisone without consulting your kidney doctor.
• Taking prednisone with food helps to decrease stomach irritation.

Possible Side Effects

Most side effects of prednisone are dose-related and may decrease or subside as the dose is reduced:

• Increased appetite and weight gain
• Salt and water retention, possibly causing swelling of face, hands or ankles
• Stomach irritation. Antacids may be prescribed if this is a problem.
• Elevated blood sugar
• Cushingoid appearance, including a tendency to have rounder cheeks
• Acne
• Mood swings
• Delayed growth
• Stretch marks
• Cataracts
• Glaucoma
• Bone disease
• Increased risk for infections

Tacrolimus (Prograf)

Prograf is a drug that suppresses the immune system and is used to prevent rejection. It is taken every day in the morning and at night.

How Prograf Is Supplied

Prograf is available as liquid or in 0.5 mg, 1 mg, and 5 mg capsules.

Special Instructions

• It is best to take Prograf at the same times each day under similar conditions (such as before or after eating). Changing conditions can change the amount of medication that is absorbed by your child's body.
• On clinic visit days, hold the morning dose of Prograf until after blood work is drawn. The Prograf dose will be adjusted based on the drug's blood level before that morning dose.
• Consult your kidney doctor before using any new medications because some drugs may affect the amount of Prograf that is absorbed into the body.
• Store at room temperature away from sunlight and moisture.

Possible Side Effects

Most side effects are dose-related and may decrease or subside as the dose is adjusted:

• Headache
• Nausea
• Diarrhea
• High blood pressure
• Tremor
• Hair loss
• Tingling of hands or feet
• Trouble sleeping
• Diabetes (elevated blood sugar)
• Abnormal kidney function
• Increased risk for infections

Cyclosporine (Neoral)

Neoral is a drug that suppresses the immune system and is used to prevent rejection after transplant. It will be taken every day in the morning and at night.

How Neoral Is Supplied

Neoral is available in liquid form or in 25 mg and 100 mg capsules.

Special Instructions

• Always take Neoral at the same time each day under similar conditions (such as before or after eating). Changing conditions can change the amount of medication that is absorbed into the body.
• On clinic visit days, you may be asked to hold the morning dose of Neoral until after blood work is drawn. The Neoral dose is adjusted based on the Neoral blood level.
• Do not give Neoral with grapefruit, pineapple or papaya juice.
• To improve the taste of liquid Neoral, mix it in a glass cup with milk, chocolate milk, orange juice or apple juice. Do not mix in a plastic, Styrofoam, or wax paper cup, as the liquid will stick to the cup.
• Store at room temperature away from sunlight and moisture.
• Consult your kidney doctor before using any new medications as some drugs may affect the amount of Neoral that is absorbed into the body, or how it is broken down in the liver.
• Schedule regular dental cleanings as Neoral can cause gums to swell and bleed.

Possible Side Effects

Most side effects are dose-related and may decrease or subside as the dose is adjusted:

• Headache
• Nausea
• Trembling or shaking of hands
• Excessive hair growth
• High blood pressure
• Swollen or bleeding gums
• Increased risk for infections
• Abnormal kidney function

Mycophenolate Mofetil (CellCept)

CellCept is given along with other immunosuppressant medications to prevent rejection after transplant. It will be taken every day in the morning and at night.

How CellCept Is Supplied

CellCept is available in liquid or in 250 mg capsules or 500 mg tablets.

Special Instructions

• Swallow the tablets or capsules whole. Do not break, open, crush, or chew them.
• Do not spill the medicine from inside the capsules or tablets into eyes, nose, mouth or on the skin. If this occurs, wash the skin with soap and water and rinse well. Rinse eyes, nose or mouth with large amounts of plain water.
• CellCept should not be used by pregnant women unless the possible benefit justifies the potential danger to the unborn baby. Women of childbearing age should use effective contraception before beginning CellCept, during the time they are taking it, and for six weeks after they have stopped taking it. Contact your kidney doctor immediately if there is the possibility of pregnancy.

Possible Side Effects

• Nausea, vomiting and diarrhea. These symptoms, if they occur, usually do so in the initial weeks of therapy and may subside with a reduction in dose. A version of the drug specially coded for protecting the stomach lining may also be used as an alternative if these problems persist or a substitute may be made to Imuran (see below).
• Reduced white blood cells and / or platelets. You will have regular blood tests to monitor these levels while taking CellCept. Be sure to report any unusual bruising or bleeding to your kidney doctor.
• Increased observed risk for infections.

Imuran (Azathioprine)

Imuran is a medication given to prevent rejection and taken once a day. It is an "older relative" of CellCept and sometimes used in its place.

How Imuran Is Supplied

Imuran comes as a 50 mg tablet that can be broken up. Some pharmacies, including the outpatient pharmacy at Cincinnati Children's, can also prepare a liquid version of Imuran for patients who have trouble taking the tablet.

Possible Side Effects

Most side effects of Imuran are not noticed by patients taking this medication but are instead picked up during routine blood tests during clinic visits:

• Decreased blood cell counts
• Liver damage
• Inflammation of the pancreas
• Vomiting or diarrhea
• Muscle aches
• Fever
• Rash

Rapamune (Rapamycin, Sirolimus)

Rapamycin is a rather new medicine used to prevent rejection. Small children usually need to take rapamycin twice a day, while older patients just need one dose a day.

How Rapamycin Is Supplied

Rapamycin comes in 1 mg and 2 mg tablets or as solution containing 1 mg/1 ml.

Special Instructions

• On clinic visit days you will be asked to hold your dose of rapamycin until after blood work is drawn. Your dose will be adjusted based on your rapamycin blood level.
• Please make sure this medicine is either taken with food or without food. It must be the same each time it is taken.
• Take the rapamycin solution with some water or orange juice, but not with grapefruit juice.

Possible Side Effects

Rapamycin can cause several side effects, and regular monitoring during clinic visits, including measurements of rapamycin blood levels, is required. Some of the side effects may require treatment, for example, adding medicines to lower cholesterol or blood pressure.

• Decreased blood cell counts
• Swelling
• High blood pressure
• High blood cholesterol and other blood fats
• Nausea, vomiting, diarrhea, constipation or tummy aches
• Headache
• Joint pain
• Fever
• Delayed wound healing
• Rash
• Trembling
• Mouth sores
• Decrease in sex hormone levels

Rapamycin delays wound healing. If your child is having surgery or dental work, call as soon as it is scheduled to taper Rapamycin and resume Prograf. After your child has healed from surgery, they will be converted back to Rapamycin.