Clinical Practice of Steroid Avoidance in Pediatric Kidney Transplantation

Abstract

Steroid‐avoidance protocols have recently gained popularity in pediatric kidney transplantation. We investigated the clinical practice of steroid avoidance among 9494 kidney transplant recipients at 124 transplant centers between 2000 and 2012 in the Organ Procurement and Transplantation Network database. The practice of steroid avoidance increased during the study period and demonstrated significant variability among transplant centers. From 2008 to 2012, 39% of transplant centers used steroid avoidance in <10% of all discharged transplant recipients. Twenty‐one percent of transplant centers practiced steroid avoidance in 10–40% of transplant recipients, and 40% of transplant centers used steroid avoidance in >40% of discharged patients. Children receiving steroid avoidance more frequently received induction with lymphocyte‐depleting agents. Repeat kidney transplants were the least likely to receive steroid avoidance. Children who received a deceased donor kidney, underwent pretransplant dialysis, were highly sensitized, or had glomerular kidney disease or delayed graft function were also less likely to receive steroid avoidance. The variation in practice between centers remained highly significant (p < 0.0001) after adjustment for all patient‐ and center‐level factors in multivariate analysis. We conclude that significant differences in the practice of steroid avoidance among transplant centers remain unexplained and may reflect uncertainty about the safety and efficacy of steroid‐avoidance protocols.

Graft survival of pediatric kidney transplant recipients selected for de novo steroid avoidance—a propensity score-matched study

“…Steroid-avoidance protocols have gained popularity in pediatric kidney transplantation and have shown acceptable outcomes compared to steroid-based regimens [1][2][3][4][5][6][7][8][9][10]. However, steroids continue to be prescribed for maintenance immunosuppression in about 65% of pediatric kidney transplant recipients, indicating that hesitancy remains regarding more widespread adoption of steroid-avoidance protocols [11]. Important concerns include appropriate identification of low-immunologic-risk patients amenable to steroid avoidance and the choice of induction agent.…”

“…We reported that children receiving steroid avoidance tended to be low-risk patients who received induction with a lymphocyte-depleting agent. The clinical practice of steroid avoidance, moreover, displayed significant variability among transplant centers: 21% of centers never practice steroid avoidance, while 26% used steroid-avoidance protocols in >60% of transplant recipients [11]. These results indicate a lack of consensus in the transplant community regarding the safe practice of steroid avoidance in pediatric kidney transplantation.…”

Estimating heterogeneous treatment effects for latent subgroups in observational studies

“…Accordingly, the 2009 Kidney Disease: Improving Global Outcomes guidelines recommend that steroids can be discontinued during the first week of transplant in patients at low immunologic risk. Despite these recommendations, steroids continue to be prescribed for maintenance immunosuppression in 65% of pediatric kidney transplant recipients . An important concern precluding more widespread adoption of steroid‐avoidance protocols is the appropriate identification of low‐immunologic risk patients in whom steroid avoidance can be safely practiced without adversely affecting long‐term allograft outcomes.…”

“…Whether steroid‐avoidance protocols adversely influence allograft survival among recipients with immunologic risk factors was previously investigated using data from the Organ Procurement and Transplantation Network (OPTN) database . Children selected for steroid‐avoidance protocols were more likely to be low‐immunologic risk patients, including non‐African–Americans and recipients of a living donor allograft . Nehus et al used propensity score matching to address confounding by indication and analyzed 3248 matched pediatric kidney transplant recipients from 2004 through 2014.…”

Reassessing Rabbit Antithymocyte Globulin Induction in Kidney Transplantation (RETHINK): An Analysis of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Registry

“… 1 The use of lymphocyte-depleting induction immunosuppression has led to significant reduction in first-year acute kidney transplant rejection rates 2 and allowed many pediatric transplant centers to adopt steroid avoidance or steroid minimization immunosuppression protocols for low-immunologic risk patients. 3 Rabbit antithymocyte globulin (rATG) is the most commonly used lymphocyte- depleting induction therapy in both adult and pediatric kidney transplant recipients. 4 However, rATG did not receive FDA approval for that induction indication until 2017.…”