Glucocorticosteroid-free versus glucocorticosteroid-containing immunosuppression for liver transplanted patients

Abstract

Many of the benefits and harms of glucocorticosteroid avoidance or withdrawal remain uncertain because of the limited number of published randomised clinical trials, limited numbers of participants and outcomes, and high risk of bias in the trials. Glucocorticosteroid avoidance or withdrawal appears to reduce diabetes mellitus and hypertension whilst increasing acute rejection, glucocorticosteroid-resistant rejection, and renal impairment. We could identify no other benefits or harms of glucocorticosteroid avoidance or withdrawal. Glucocorticosteroid avoidance or withdrawal may be of benefit in selected patients, especially those at low risk of rejection and high risk of hypertension or diabetes mellitus. The optimal duration of glucocorticosteroid administration remains unclear. More randomised clinical trials assessing glucocorticosteroid avoidance or withdrawal are needed. These should be large, high-quality trials that minimise the risk of random and systematic error.

<p>Improving Patient Outcomes Following Pediatric Liver Transplant: Current Perspectives</p>

“…Based on a recent study by Fairfield and colleagues, patients that were being managed with steroid withdrawal or avoidance protocols had increased risk of acute rejection (RR 1.33) and steroid resistant rejection (RR 2.14). 10 This Cochrane meta-analysis also looked at mortality and graft loss but found no statistically significant differences between steroid avoidance/withdrawal vs steroid containing regimens. 10 Transplant recipients are also maintained with calcineurin inhibitors (CNIs) that prevent downstream IL-2 signaling and T cell proliferation and responses.…”

“…10 This Cochrane meta-analysis also looked at mortality and graft loss but found no statistically significant differences between steroid avoidance/withdrawal vs steroid containing regimens. 10 Transplant recipients are also maintained with calcineurin inhibitors (CNIs) that prevent downstream IL-2 signaling and T cell proliferation and responses. With the introduction of calcineurin inhibitors, first cyclosporine and then tacrolimus, graft survival dramatically increased.…”

Simultaneous Liver‐Kidney Transplant: Long‐Term Management (Steroid Withdrawal and Safety Net Patients)

“…In the LTA population, the experience with ECSWD has recently been summarized in a meta‐analysis of 16 studies with 1347 participants . The main findings of this metaanalysis were consistent with the KTA experience in that although graft loss and mortality were similar, the adjusted relative risk (RR) for rejection was 1.33 (95% confidence interval [CI], 1.08‐1.64) with ECSWD compared with CCS (Fig.…”

Hepatocellular cancer and recurrence after liver transplantation: what about the impact of immunosuppression?

“…The use of azathioprine (AZA), another antimetabolite known to induce non-skin malignancy in LT, has not been analysed in respect of HCC recurrence (67). The same can be stated for the use of corticosteroids, anti-lymphocytic sera and anti-interleukin-2 receptor α antibodies (46,58,(68)(69)(70)(71)(72)(73).…”