eng Oriental Scientific Publishing Company Biomedical and Pharmacology Journal 0974-6242 2021-09-30 14 3 1149 1159 10.13005/bpj/2218 40745 article Fatina I Fadel 1 Abeer M Nour ElDin Abd ElBaky 2 Mohamed A Abdel Mawla 2 Wesam I Moustafa 3 Gamal Eldin Saadi 4 Doaa M Salah 1 Department of Pediatrics, Cairo University, Cairo, Egypt Department of Pediatrics, National Research Center, Giza, Egypt Department of Pathology, Bani Suef University, BaniSuef, Egypt Department of Internal Medicine, Cairo University, Cairo, Egypt Background: By the time of histological confirmation of rejection is achieved, renal scarring may for treatment as a  realistic option . This study aims to study the subclinical pathological graft data and to evaluate the histopathological impact of different immunosuppression protocols in pediatric renal transplant recipients. Methods: This is a case series that included twenty living donor renal transplant recipients. All included cases received the classic triple immunotherapy for at least one month post-transplantation [Steroids, calconurine inhibitors (CNI), and mycofenlolic mofetile (MMF)]. Based on their immunological risk stratification; included cases were divided into 2 groups: group (A) continued on CNI based triple therapy protocol; group (B) shifted to evirolimus /low dose CNI protocol. Surveillance biopsies were done for all cases at one and four month post-transplantation. Results: One and four month biopsies revealed subclinical rejection (including borderline changes) in 4 (20%) cases and 6 (30%) cases respectively. The number of patients received tacrolimus/MMF therapy significantly increased (p=0.02) while that of patients on everloimus/low dose CNI significantly decreased (p=0.014) due to drug modifications based on four month surveillance biopsy data. Conclusion: Subclinical rejection is not uncommon in pediatric renal graft recipients which makes surveillance biopsy might be of help. Early usage of evirolimus/low CNI protocol is associated with higher rejection rate than triple therapy. https://biomedpharmajournal.org/vol14no3/subclinical-rejection-and-immunosuppression-in-pediatric-kidney-transplant-recipients-single-centre-study/  Immunosuppression Pediatric Transplantation Surveillance biopsy