Azathioprine and Steroids

Complete Steroid Avoidance Is Effective and Safe in Children With Renal Transplants: A Multicenter Randomized Trial With Three-Year Follow-Up

“…Though this clinical study cannot dissect the specific impact of extended dose daclizumab from the impact of complete steroid avoidance, it is possible that the prolonged use of daclizumab was a key immunomodulatory agent that diminished the risk of acute rejection recurrence. On the other hand, evaluating literature on the effect of chronic steroids in animal and human models of organ transplantation (5;8–11;34;35), we can hypothesize that the higher rejection recurrence rate in the SB arm may reflect an element of steroid dependence. The clinical significance of the numerically higher rate of borderline changes in protocol biopsies at 12 and 24 months post-transplantation is yet unclear (36), and was counterbalanced by numerically higher number of patients that developed acute T-cell mediated rejection after one year in the SB group.…”

“…Unfortunately, steroid use is a two-edged sword, with side effects that are particularly serious for children, including growth retardation with reduced final adult height (2;3), body disfigurement (often leading to medication nonadherence), hypertension, hyperlipidemia, diabetes mellitus, acne, osteopenia and increased infection risk (4;5). …”

“…Early attempts at steroid withdrawal in renal transplant recipients were associated with high rates of subsequent acute rejection (6;7), leading to the belief that chronic steroid usage resulted in immune dependence (5;8–11). More recent trials of steroid withdrawal or avoidance in adult recipients, who received induction therapy and more powerful maintenance therapy, have shown variable results.…”

Steroid sparing protocols following nonrenal transplants; the evidence is not there. A systematic review and meta-analysis

“…During the subsequent development of transplantation immunosuppression, corticosteroids became a mainstay of maintenance drug therapy – a practice which later extended to regimens used in the transplantation of other solid organs. Corticosteroid use is associated with many side effects [2], but the development of newer, more effective, induction and maintenance agents has led to a great interest in dose reduction, withdrawal, and even complete avoidance of steroids following transplantation.…”