Follow-Up of Cyclosporine-Treated Pediatric Renal Allograft Recipients After Cessation of Prednisone

Reisman, Lewis; Lieberman, Kenneth V.; Burrows, L; Schanzer, Harry

doi:10.1097/00007890-199001000-00017

Cited by 100 publications

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“…Justification for the continued use of corticosteroids has been based on (1) early reports that steroid withdrawal after transplantation is associated with breakthrough ACR (11)(12)(13)(14)22,23,25); (2) the known anti-inflammatory capacity of steroids, leading to the argument that removing prednisone might cause more renal scarring; and (3) the long-term data of Sinclair et al (15) in which kidney transplant recipients who were randomly assigned at 3 mo after transplantation to steroid withdrawal had a significantly worse graft survival compared with control subjects (73 versus 85%). We believe that chronic corticosteroid use needs to be reconsidered in the context of new emerging data such as in this report and by examining some of the pitfalls of previous steroid withdrawal studies.…”

Section: Discussionmentioning

confidence: 99%

“…GFR was calculated at different time points after transplant (3,6,12,24,36,48, and 60 mo) using the abbreviated Modification of Diet in Renal Disease (MDRD) equation (36).…”

Section: Renal Allograft Function Measurementmentioning

confidence: 99%

“…In the pre-mycophenolate mofetil (pre-MMF) era, despite the adverse effects associated with steroid therapy, the risk for increased rejection with steroid discontinuation often has outweighed the potential benefits of improved quality of life (11)(12)(13)(14). Results from a meta-analysis of seven randomized, controlled trials during this period suggested that avoiding steroid therapy from the time of transplantation or withdrawing steroid therapy at some time after transplantation increased the risk for acute allograft rejection (2).…”

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confidence: 99%

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Effect of Prednisone versus No Prednisone as Part of Maintenance Immunosuppression on Long-Term Renal Transplant Function

Gallon

Winoto

Leventhal

et al. 2006

Clinical Journal of the American Society of Nephrology

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Corticosteroids have been a component of maintenance immunosuppression for renal transplant since the 1960s and have helped to reduce the rate of acute rejection. Corticosteroids, however, have many adverse effects, and with the development of new immunosuppressive medications, many transplant centers have adopted protocols that eliminate or completely avoid the use of corticosteroids. Despite promising short-term results, the impact of corticosteroid elimination on long-term kidney function still is unclear. This single-center, retrospective, sequential study analyzed 212 renal transplant patients with a median follow-up of 5 yr. All patients received induction with IL-2 receptor antagonist and maintenance immunosuppression with mycophenolate mofetil and tacrolimus. Ninety-six patients were maintained on chronic prednisone, and 116 were maintained without chronic prednisone (rapid steroid elimination). Kaplan-Meier patient and graft survival at 7 yr after transplantation were not statistically different between the two groups. Rate and severity of acute cellular rejection were similar. Furthermore, the slope of GFR decline per month at 5 yr after transplantation was not statistically different between the two groups. Prednisone-treated patients had a significantly higher incidence of hyperlipidemia and posttransplantation diabetes when compared with patients with rapid steroid elimination. It was concluded that with the current immunosuppressive medications, the use of chronic prednisone to maintain long-term kidney function and prevent acute cellular rejection is not justified.

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Section: Discussionmentioning

confidence: 99%

“…GFR was calculated at different time points after transplant (3,6,12,24,36,48, and 60 mo) using the abbreviated Modification of Diet in Renal Disease (MDRD) equation (36).…”

Section: Renal Allograft Function Measurementmentioning

confidence: 99%

mentioning

confidence: 99%

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Effect of Prednisone versus No Prednisone as Part of Maintenance Immunosuppression on Long-Term Renal Transplant Function

Gallon

Winoto

Leventhal

et al. 2006

Clinical Journal of the American Society of Nephrology

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“…However, centres that have employed the avoidance or rapid elimination approach report excellent patient and graft survival, as well as low rates of acute rejection (0-10%) in small series of low-risk kidney recipients [8][9][10][11][12]. In contrast, other centres have found that rates of rejection are higher in recipients undergoing rapid corticosteroid discontinuation than in those maintained on corticosteroid therapy, though there was no impact on renal function [13,14]. Interestingly, protocol biopsies obtained from the corticosteroid withdrawal group revealed higher levels of transforming growth factor-b and greater fibrosis.…”

Section: Discussionmentioning

confidence: 99%

A large, prospective, randomized, open-label, multicentre study of corticosteroid withdrawal in SPK transplantation: a 3-year report

Nakache¹,

Malaise²,

Ophem³

2005

Nephrology Dialysis Transplantation

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Background. Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for selected diabetic patients. Corticosteroids are an important element of immunosuppressive protocols, but their long-term use has detrimental effects on patients' health, necessitating eventual discontinuation. Methods. This prospective study evaluated the safety and feasibility of corticosteroid withdrawal in 205 SPK transplant recipients randomized to immunosuppressive treatment with either tacrolimus and mycophenolate mofetil (MMF) (n ¼ 103) or cyclosporin microemulsion (ME) and MMF (n ¼ 102). Results. Corticosteroid withdrawal was successful in the majority of in-study patients (66% tacrolimus, 73% cyclosporin-ME). Compared with out-of-study patients or those continuing corticosteroid therapy, in-study patients withdrawn from corticosteroids experienced fewer pancreas or kidney graft losses, fewer episodes of acute rejection and were less likely to be withdrawn from the study. Acute rejection occurred after corticosteroid withdrawal in two patients who had a previous rejection and in five patients who were rejection-free before corticosteroid withdrawal. No rejection episodes were associated with graft loss or immediate serious consequences. Overall, corticosteroid withdrawal was achieved with an increase in the dose of both MMF and tacrolimus. Conclusions. A long-term survey of corticosteroid withdrawal in SPK transplantation with multifactorial analyses is necessary to confirm these early results and to evaluate the positive effects on glucose metabolism and hypertension.

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“…However, this strategy may increase the incidence of acute or chronic allograft rejection and graft loss [1]. Moreover, since the required glucocorticoid dose to achieve optimal immunosuppression is unknown, glucocorticoid dosing and subsequent tapering is performed empirically.…”

Section: Introductionmentioning

confidence: 99%

A study on strategies for improving growth and body composition after renal transplantation

Ferraris

Pasqualini²,

Alonso³

et al. 2010

Pediatr Nephrol

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Allograft function and metabolic effects of four treatment regimens, namely, methylprednisone (MP) standard dose (MP-STD), deflazacort (DFZ), MP-late steroid withdrawal (MP-LSW), and MP-very low dose (MP-VLD), were evaluated in prepubertal patients. MP was decreased by month 4 post-transplantation to 0.2 mg/kg/day in MP-STD and DFZ patients and to <0.1 mg/kg/day in MP-LSW and MP-VLD patients. Starting in month 16 post-transplant, MP was switched to DFZ in the DFZ group and totally withdrawn in the MP-LSW group. Creatinine clearance diminished in the MP-STD and MP-LSW groups from 77 +/- 6 to 63 +/- 6 ml/min/1.73 m(2)and from 103 +/- 5 to 78 +/- 3 ml/min/1.73 m(2), respectively (p < 0.01 and p < 0.001, respectively). Height increased >0.5 SDS only in the MP-LSW and MP-VLD groups. The body mass index and fat body mass for height-age increased only in the MP-STD patients (p < 0.05 and p < 0.01, respectively). Fat body mass decreased in the DFZ group (p < 0.05), total cholesterol and LDL-cholesterol increased in the MP-STD group, while LDL-cholesterol and total cholesterol/HDL-cholesterol ratio decreased in the DFZ group (p < 0.01). Lumbar spine bone mineral density (BMD) for height-age showed an increase in the MP-LSW and MP-VLD groups (p < 0.01). Our data suggest that MP-LSW and MP-VLD strategies improve linear growth, BMD, the peripheral distribution of fat, and preservation of the bone-muscle unit and maintain the normal lipid profile. The MP-LSW patients had a concerning rate of acute rejections and graft function deterioration in prepubertal patients.

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Follow-Up of Cyclosporine-Treated Pediatric Renal Allograft Recipients After Cessation of Prednisone

Cited by 100 publications

References 0 publications

Effect of Prednisone versus No Prednisone as Part of Maintenance Immunosuppression on Long-Term Renal Transplant Function

Effect of Prednisone versus No Prednisone as Part of Maintenance Immunosuppression on Long-Term Renal Transplant Function

A large, prospective, randomized, open-label, multicentre study of corticosteroid withdrawal in SPK transplantation: a 3-year report

A study on strategies for improving growth and body composition after renal transplantation

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