**7.2. Calcineurin inhibitor avoidance/minimization/withdrawal**

Several studies have looked at minimizing exposure to CNIs to over come nephrotoxicity. Complete calcineurin avoidance with de novo use of sirolimus has not been successful and was associated with higher incidence of rejections and graft loss. [43]. Due to this, more centers and studies have favored calcineurin minimization and withdrawal (at 3 to 6 months post transplant) as opposed to complete avoidance. The ELITE-symphony trial was a land mark trial comparing different regimens of calcineurin minimization and withdrawal demonstrat‐ ing better allograft outcomes at three years of follow up in patients on low dose tacrolimus (in addition to steroids and MMF) than standard dose cyclosporine, reduced dose cyclosporine or low dose sirolimus as primary maintenance agent. [44] A recent meta-analysis evaluating calcineurin minimization strategies concluded that calcineurin minimization decreases rates of graft failure, incidence of delayed graft function, and new onset diabetes post transplant while avoiding an increased risk of acute rejection. [55].
