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Coelho T, Tredger M, Dhawan A. Current status of immunosuppressive agents for solid organ transplantation in children. 
Pediatr Transplantation 2012: 16: 106–122. © 2012 John Wiley & Sons A/S. Abstract:  Immunosuppression after organ transplantation is complex and ever evolving. Over the past two decades, newer immunosuppressive agents have been introduced with an aim to provide better patient and graft survival. Improved therapeutic strategies have been developed offering the option to use combinations of drugs with non‐overlapping toxicities. There are, however, only a few clinical studies with robust data to rationalize the use of these agents in children. This review will discuss the newer immunosuppressive agents used for solid organ transplant, their current status in post‐transplant management and prevention of allograft rejection.

Background: Glomerular filtration rate (GFR) and mortality is more accurately determined by gold standard measures than serum creatinine-based estimates in cirrhosis. No formal validation of any gold standard method has been reported. Methods: An isocratic methanol-based method incorporating the reference standard iohexol-related compound C was developed and validated in 12 patients with cirrhosis by simultaneously determining GFR using iohexol and chromium-51 labelled ethylenediamine tetraacetic acid ( 51 Cr-EDTA) clearance. Iohexol pharmacokinetics was also studied with the collection of blood and ascitic fluid at intervals following an iohexol bolus. Results: Triplicate assays produced a linear calibration curve (R 2 ¼ 0.99, N ¼ 5) over an iohexol concentration range of 23.6-755 mg/L. Mean (range) extraction recovery of iohexol from serum was greater than 95% (94-97%), with an intraday coefficient of variation less than 3%. Twelve patients with cirrhosis with mean Child-Pugh score of 9 displayed a mean difference (bias) À1.3 mL/min/1.73 m 2 (À18 to þ 16) comparing iohexol with 51 Cr-EDTA. Iohexol equilibrated between blood and ascitic compartments after 4 h. Conclusion: A simple, cheap, and accurate isocratic, methanol-based method for the determination of iohexol concentrations is described, validated according to Food and Drug Administration guidance. Iohexol demonstrated comparable performance with 51 Cr-EDTA in determining GFR. Delayed equilibrium of iohexol between blood and ascitic compartments suggests sampling beyond 4 h would improve accuracy of GFR determinations in patients with cirrhosis.