Renal Transplantation with Early Steroid Withdrawal

Overview

Journal Pediatr Nephrol

Specialties Nephrology
Pediatrics

Date 2008 Jun 7

PMID 18535842

Citations 4

Authors

Jeffrey Schiff

Edward H Cole

Affiliations

Soon will be listed here.

Abstract

Steroids are effective immunosuppressants in renal transplantation but are associated with significant adverse effects. As a result, there has been increased interest in protocols utilizing steroid minimization. Initial trials stopped steroids at approximately 3 months, when the highest risk phase for acute rejection was over. As two randomized trials using cyclosporine and mycophenolate mofetil without induction therapy showed an unacceptably high acute rejection rate, more recent interest has focused on the cessation of steroids very early, usually within the first week after transplantation. Most protocols have used antibody induction combined with calcineurin inhibitors and mycophenolic acid derivatives. Uncontrolled studies have shown a low rate of acute rejection, but the most recent randomized controlled trials have demonstrated an increased risk of acute rejection. These trials have not shown any consistent difference in short-term patient or graft survival. Cardiovascular risk factors do not appear to be consistently improved by early steroid withdrawal. Most trials lack sufficient follow-up (5 years or more) to assess the impact of the increased acute rejection rate seen with early steroid withdrawal on long-term outcomes. Thus, the use of such protocols remains investigational.

Citing Articles

Role of steroid maintenance in sensitized kidney transplant recipients.

Sureshkumar K, Marcus R, Chopra B World J Transplant. 2015; 5(3):102-9.

PMID: 26421263 PMC: 4580925. DOI: 10.5500/wjt.v5.i3.102.

Impact of steroid maintenance on the outcomes in first-time deceased donor kidney transplant recipients: Analysis by induction type.

Sureshkumar K, Hussain S, Thai N, Ko T, Nashar K, Marcus R World J Transplant. 2014; 4(3):188-95.

PMID: 25346892 PMC: 4208082. DOI: 10.5500/wjt.v4.i3.188.

Influence of steroid maintenance on the outcomes in deceased donor kidney transplant recipients experiencing delayed graft function.

Tangirala B, Marcus R, Hussain S, Sureshkumar K Indian J Nephrol. 2013; 23(6):403-8.

PMID: 24339515 PMC: 3841505. DOI: 10.4103/0971-4065.120328.

Ten-year outcome after rapid discontinuation of prednisone in adult primary kidney transplantation.

Rizzari M, Suszynski T, Gillingham K, Dunn T, Ibrahim H, Payne W Clin J Am Soc Nephrol. 2012; 7(3):494-503.

PMID: 22282482 PMC: 3302679. DOI: 10.2215/CJN.08630811.

References

Ekberg H, Tedesco-Silva H, Demirbas A, Vitko S, Nashan B, Gurkan A . Reduced exposure to calcineurin inhibitors in renal transplantation. N Engl J Med. 2007; 357(25):2562-75. DOI: 10.1056/NEJMoa067411. View

Farmer C, Hampson G, Abbs I, Hilton R, Koffman C, Fogelman I . Late low-dose steroid withdrawal in renal transplant recipients increases bone formation and bone mineral density. Am J Transplant. 2006; 6(12):2929-36. DOI: 10.1111/j.1600-6143.2006.01557.x. View

Rostaing L, Cantarovich D, Mourad G, Budde K, Rigotti P, Mariat C . Corticosteroid-free immunosuppression with tacrolimus, mycophenolate mofetil, and daclizumab induction in renal transplantation. Transplantation. 2005; 79(7):807-14. DOI: 10.1097/01.tp.0000154915.20524.0a. View

Hricik D, OToole M, Schulak J, Herson J . Steroid-free immunosuppression in cyclosporine-treated renal transplant recipients: a meta-analysis. J Am Soc Nephrol. 1993; 4(6):1300-5. DOI: 10.1681/ASN.V461300. View

Vincenti F, Schena F, Paraskevas S, Hauser I, Walker R, Grinyo J . A randomized, multicenter study of steroid avoidance, early steroid withdrawal or standard steroid therapy in kidney transplant recipients. Am J Transplant. 2008; 8(2):307-16. DOI: 10.1111/j.1600-6143.2007.02057.x. View

Haririan A, Sillix D, Morawski K, El-Amm J, Garnick J, Doshi M . Short-term experience with early steroid withdrawal in African-American renal transplant recipients. Am J Transplant. 2006; 6(10):2396-402. DOI: 10.1111/j.1600-6143.2006.01477.x. View

Vincenti F, Monaco A, Grinyo J, Kinkhabwala M, Roza A . Multicenter randomized prospective trial of steroid withdrawal in renal transplant recipients receiving basiliximab, cyclosporine microemulsion and mycophenolate mofetil. Am J Transplant. 2003; 3(3):306-11. DOI: 10.1034/j.1600-6143.2003.00005.x. View

Matas A, Kandaswamy R, Gillingham K, McHugh L, Ibrahim H, Kasiske B . Prednisone-free maintenance immunosuppression-a 5-year experience. Am J Transplant. 2005; 5(10):2473-8. DOI: 10.1111/j.1600-6143.2005.01051.x. View

Klaus G, Jeck N, Konrad M, Forster B, Soergel M . Risk of steroid withdrawal in pediatric renal transplant patients with suspected steroid toxicity. Clin Nephrol. 2002; 56(6):S37-42. View

10.

Sarwal M, Yorgin P, Alexander S, Millan M, Belson A, Belanger N . Promising early outcomes with a novel, complete steroid avoidance immunosuppression protocol in pediatric renal transplantation. Transplantation. 2001; 72(1):13-21. DOI: 10.1097/00007890-200107150-00006. View

11.

Andreoni K, Brayman K, Guidinger M, Sommers C, Sung R . Kidney and pancreas transplantation in the United States, 1996-2005. Am J Transplant. 2007; 7(5 Pt 2):1359-75. DOI: 10.1111/j.1600-6143.2006.01781.x. View

12.

Anil Kumar M, Heifets M, Moritz M, Saeed M, Khan S, Fyfe B . Safety and efficacy of steroid withdrawal two days after kidney transplantation: analysis of results at three years. Transplantation. 2006; 81(6):832-9. DOI: 10.1097/01.tp.0000203558.34739.c6. View

13.

Woodle E, Alloway R, Buell J, Alexander J, Munda R, Roy-Chaudhury P . Multivariate analysis of risk factors for acute rejection in early corticosteroid cessation regimens under modern immunosuppression. Am J Transplant. 2005; 5(11):2740-4. DOI: 10.1111/j.1600-6143.2005.01090.x. View

14.

van den Ham E, Kooman J, Christiaans M, van Hooff J . The influence of early steroid withdrawal on body composition and bone mineral density in renal transplantation patients. Transpl Int. 2003; 16(2):82-7. DOI: 10.1007/s00147-002-0488-8. View

15.

Khwaja K, Asolati M, Harmon J, Melancon J, Dunn T, Gillingham K . Rapid discontinuation of prednisone in higher-risk kidney transplant recipients. Transplantation. 2004; 78(9):1397-9. DOI: 10.1097/01.tp.0000136964.59494.ff. View

16.

Lau K, Haddad M, Berg G, Perez R, Butani L . Rapid steroid discontinuation for pediatric renal transplantation: a single center experience. Pediatr Transplant. 2007; 11(5):504-10. DOI: 10.1111/j.1399-3046.2007.00713.x. View

17.

Matas A, Ramcharan T, Paraskevas S, Gillingham K, Dunn D, Gruessner R . Rapid discontinuation of steroids in living donor kidney transplantation: a pilot study. Am J Transplant. 2002; 1(3):278-83. DOI: 10.1034/j.1600-6143.2001.001003278.x. View

18.

ter Meulen C, van Riemsdijk I, Hene R, Christiaans M, Borm G, Corstens F . No important influence of limited steroid exposure on bone mass during the first year after renal transplantation: a prospective, randomized, multicenter study. Transplantation. 2004; 78(1):101-6. DOI: 10.1097/01.tp.0000133513.29923.44. View

19.

Oberholzer J, John E, Lumpaopong A, Testa G, Sankary H, Briars L . Early discontinuation of steroids is safe and effective in pediatric kidney transplant recipients. Pediatr Transplant. 2005; 9(4):456-63. DOI: 10.1111/j.1399-3046.2005.00319.x. View

20.

Kasiske B, Chakkera H, Louis T, Ma J . A meta-analysis of immunosuppression withdrawal trials in renal transplantation. J Am Soc Nephrol. 2000; 11(10):1910-1917. DOI: 10.1681/ASN.V11101910. View