Objective: Renal transplant is now the best treatment for end stage renal failure. To avoid rejection and prolong graft function, organ recipients need immunosuppressive therapy. Renal transplant recipient maintenance treatment is mostly based on triple drug therapy containing calcineurin inhibitors, corticosteroids and anti proliferative drugs. In addition to the desired effect, the drugs caries risks of certain side effects. There are different clinical trails support the use of Everolimus as a standard immunosuppressive drug associated with reduced exposure of CI in kidney transplant. Here we are presenting a case of de novo use of Everolimus in renal transplant patient and its 3 months outcome to support this practice, discuss  side effects and offer its safe use, avoiding complications.
Methods: Our patient is 33 year old male chronic kidney disease with graft dysfunction (first renal transplant in 2017) on maintenance hemodialysis underwent  deceased donor renal transplant in October 2023 (second transplant). Patient was started with triple immunosuppressive drugs Tacrolimus, Mycofenolate mofetil and corticosteroid as per our institute protocol. Post operatively patient underwent rejection, considering humoral rejection patient underwent plasmapheresis and given injection Rituximab in post operative period. I/V/O  decreasing CNI exposure and salvage graft function we added M TOR inhibitor and discharged patient on quadruple immunosuppressive drug regimen with creatinine 1.92 mg/dl.
Results: Post operatively patient admitted after 2 months with pneumonia with sepsis as well as acute graft dysfunction with lymphocele formation.Patient was treated with higher antibiotics and immunosuppressive drugs reduced accordingly.patient underwent surgical exploration I/v/o lymphocyte collection and treated with marsupialisation for the same.later on patient’s creatinine start decreasing gradually and patient improved symptomatically.patient was discharged with creatinine 1.7 mg/dl.Again patient was admitted after 1 month with acute graft dysfunction, deep vein thrombosis,pneumonia as well as lymphocyte collection.As it was second episode we again reduced the dose of immunosuppressive medication.patient underwent surgery for the lymphocyte collection.post operatively patient had persistent high drain volume and anasarca with pneumonitis like symptoms.suspecting everolimus toxicity we decided to hold everolimus for some days and continued with triple immunosuppressive drugs.gradually patient condition improved and graft function stabilised.
Conclusion: De novo use of M TOR inhibitors allow a reduced exposure to CNIs during the first few weeks post transplant, however it may affect post operative healing. De novo use of everolimus require careful monitoring of drug level as well as clinical assessment of transplant patients more frequently. We need to balance the side effects associated with CNI exposure in high risk renal transplant patients and cautious use of M TOR inhibitors can be improved with further knowledge and experiences.