Rapid steroid discontinuation for pediatric renal transplantation: A single center experience

Abstract

To determine the outcomes of pediatric renal transplant recipients who received immunosuppression consisting of early withdrawal of corticosteroids at a single Northern California center. Protocols using minimal steroid exposure have been recently reported in adult transplant recipients with successful results. We examined the outcomes of pediatric renal transplant recipients who were managed at our center using a protocol with very early discontinuation of steroids after renal transplantation. We retrospectively studied the medical records of all renal transplant recipients followed at the Children's Hospital at the University of California, Davis Medical Center from 01/2004 to 12/2005. All patients were less than 18 yr of age at the time of transplantation. The immunosuppressive protocol included three tapering daily doses of methylprednisolone, together with five doses of thymoglobulin followed by maintenance therapy with tacrolimus and MMF. Eight patients with equal numbers of males and females were transplanted during this time period. There were equal numbers of Caucasians, African-Americans, Hispanics, and Asians. A total of 37.5% (3/8) of the subjects received preemptive transplantation, 25% (2/8) received peritoneal, and 37.5% (3/8) received hemodialysis before transplantation. The median (range) age at transplantation was 12.3 (3.1-16.0) year with a follow-up of 1.7 (0.9-2.8) year. At one yr post-transplantation, 57% (4/7) of patients still required anti-hypertensives. Three children required erythropoietin supplementation after transplantation. The mean delta height standard deviation score at 12 months was 0.20 +/- 0.56. There were no episodes of clinical acute rejection. One patient switched from tacrolimus to sirolimus due to biopsy-proven CAN. No patient became diabetic or required hypoglycemic agents. Surveillance biopsies showed no subclinical acute rejection in any patient. Steroid-free immunosuppression is safe in children after renal transplantation. Larger number of patients and longer follow-up are required to further confirm the effectiveness and safety of immunosuppression with rapid steroid discontinuation.

Steroid Minimization in Pediatric Renal Transplantation

“…Since the first anecdotal success by Birkeland et al with the use of a steroid free regimen in 14 pediatric patients, many centers, including ours, have reported their successful experience with steroid minimization in pediatric allograft recipients, using various novel protocols in a non-randomized manner [17][18][19][20][21][22][23][24]. These reports not only further support the feasibility and safety of steroid avoidance or minimization but they also affirm the potential metabolic benefits observed in adult patients.…”

Rapid Discontinuation of Prednisone in Kidney Transplant Recipients

“…43–46 Additional support for this concept comes from the prospective randomized trials of Belatacept versus CsA maintenance therapy, in which the Belatacept cohort has had an increased AR rate but no decrease in patient or graft survival. 47,48 …”

Long‐term outcome of pediatric renal transplantation: The Norwegian experience in three eras 1970–2006

“…The struggle for improving outcome in pediatric renal transplantation has resulted in the development of more potent maintenance immunosuppressive and induction therapies. Various combinations of these have in recent years allowed lower dosage, early withdrawal or even avoidance of steroids (6–9), and strategies are sought to minimize nephrotoxic effects of CNI (10–12). Protocol biopsies are currently elucidated for better surveillance of the renal graft (13, 14).…”