triple drug regimen, which includes cyclosporine, azathioprine and corticoster-oids. A new oral formulation of cyclosporin has improved intestinal absorption even in the setting of poor bile flow.15,16 This is particularly valuable for small infants who typically require large doses of cyclosporine secondary to poor intestinal absorption. Cyclosporine is usually administered intravenously during the initial postoperative period, but the oral preparation can be absorbed adequately even on the first postoperative day. The cyclosporine dose is adjusted to yield a 12-hour trough level of 250-350 ng/ml as measured by TDX. Azathioprine is administered at a constant dose of 1 mg/kg/day and methylprednisolone or prednisone doses are gradually tapered from 2mg/kg/day to .3 mg/kg/day over the first month. Tacrolimus is gaining acceptance as an alternative to cyclosporine in pedi-atric liver transplant recipients. Because it is more potent than cyclosporine, patients treated with tacrolimus are less dependent on steroid administration, and may avoid steroid related complications, such as growth failure and hypertension. Unfortunately, tacrolimus can be difficult to administer to smaller children since it is not available in a liquid formulation. It does not cause the cosmetic side effects associated with cyclosporine, but it may contribute to anorexia and chronic gastrointestinal symptoms, which are not common in children treated with cyclosporine. There is also a growing concern that post transplant lympho-proliferative disease (PTLD) is more common in children who have received tacrolimus.

The use of monoclonal antilymphocyte antibodies, such as OKT3, either for induction or for treatment of steroid resistant rejection is becoming less common in pediatrics since this therapy has also been identified as a risk factor for PTLD.17 Chimeric antibody preparations for specific T-cell markers are being tested in pediatric solid organ recipients and may prove to be safe and effective alternatives to current antilymphocyte therapy.

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