Fig. 4
Clinical decision-making algorithm for initiating sirolimus therapy. Before converting to SRL, check the baseline eGFR and proteinuria. If baseline eGFR ≥60 or <60 mL/min/1.73 m2 without baseline proteinuria, initiation of SRL can be considered. Among patients with baseline eGFR <60 mL/min/1.73 m2 and positive proteinuria, conversion to SRL requires careful evaluation. During SRL therapy, regular monitoring of the eGFR and for proteinuria is required. For patients with new onset proteinuria, re-evaluation of the necessity of SRL, switching immunosuppression regimens, or SRL discontinuation may be considered