Corticosteroid minimization in renal transplantation: Careful patient selection enables feasibility

Abstract

AIMTo explore the benefits and harms of corticosteroid (CS) minimization following renal transplantation.METHODSCS minimization attempts to improve cardiovascular risk factors (hypertension, diabetes, dyslipidemia), to enhance growth in children, to ameliorate bone disease and to lead to better compliance with immunosuppressive agents. Nevertheless, any benefit must be carefully weighed against the reduction in net immunosuppression and the potential harm to renal allograft function and survival.RESULTSComplete CS avoidance or very early withdrawal (i.e., no CS after post-transplant day 7) seems to be associated with better outcomes in comparison with later withdrawal. However, an increased incidence of CS-sensitive acute rejection has been observed with all CS minimization strategies. Among the prerequisites for the safe application of CS minimization protocols are the administration of induction immunosuppression and the inclusion of calcineurin inhibitors in maintenance immunosuppression regimens.CONCLUSIONTransplant recipients at low immunological risk (primary transplant, low panel reactive antibodies) are thought as optimal candidates for CS minimization. CS avoidance may also be undesirable in patients at risk for glomerulonephritis recurrence or with severe delayed graft function and prolonged cold ischemia time. Thus, CS minimization is not yet ready for implementation in the majority of transplant recipients.

Defining a Steroid Withdrawal Protocol in a newly established Kidney Transplantation Unit

“…Patient and graft survival rates remained the same in all study groups at 12 months review point [7,31].…”

“…At a 12 months follow up, there was no variation in graft performance and rate of AR amongst the 2 groups. Interstitial fi brosis was, however, prominent in biopsies at 12 months in the withdrawal group [7,33].…”

“…Steroid withdrawal at 3-6 months after transplantation is categorized as early withdrawal while withdrawal after 6 months and above after transplantation is considered as late withdrawal [1,7].…”

“…In a group of patients steroids were withdrawn at 3 months. On review of the cases at 6 months, an increased AR rate and reduced cholesterol and low density lipoprotein (LDL) were noted in the steroid withdrawal group commencing from the period 3 up to 6 months post transplantation, refer to table 1 [7,15].…”

“…While using basiliximab as an induction agent and a CNI and MMF or sirolimus as maintenance, Kumar et al, in a study of 300 kidney transplant recipients compared steroid withdrawal at 2 days versus non-withdrawal and recorded no variation between the 2 groups in AR recipient and graft survival and function except for a slight occurrence of NODAT in the steroid withdrawal group [7,32].…”