Steroid withdrawal in pediatric and adult renal transplant recipients

Tönshoff, Burkhard; Höcker, Britta; Weber, Lutz T.

doi:10.1007/s00467-004-1765-9

Cited by 27 publications

(15 citation statements)

References 36 publications

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“…This might be due to the fact that prolonged use of corticosteroids stimulates cytokine receptors on T‐cells, so that late withdrawal of steroids may lead to the release of cytokines in an environment with the receptors already being up‐regulated, thus increasing the risk of rejection (23). However, a recent report of late steroid withdrawal in pediatric renal recipients showed no increased risk of acute rejections with a mean follow‐up of 46 months (24, 25), indicating that this may be another alternative to steroid minimization.…”

Section: Discussionmentioning

confidence: 99%

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

Lau¹,

Haddad²,

Berg³

et al. 2007

Pediatric Transplantation

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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.

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Section: Discussionmentioning

confidence: 99%

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

Lau¹,

Haddad²,

Berg³

et al. 2007

Pediatric Transplantation

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“…The optimistic data from the clinical trials suggest a rather moderate or transient role of rhGH on the immune system. Steroid withdrawal and rhGH treatment are still controversially discussed [65][66][67]. Insensitivity to the action of GH in CRF is unavoidable even with optimized conservative treatment and modern renal replacement therapy, whereas the responsibility for hyporesponsiveness to the action of GH after renal Tx is due to corticosteroids as long as GFR is satisfactory (>60 ml/min per 1.73 m 2 ).…”

Section: Impact Of Rhgh Therapy On Lymphocyte Functionmentioning

confidence: 98%

Longitudinal growth in children following kidney transplantation: from conservative to pharmacological strategies

Ulinski

Cochat

2006

Pediatr Nephrol

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Impairment of longitudinal growth in children with chronic renal failure (CRF) is multifactorial. It is mainly due to disturbances in the growth hormone (GH)/insulin-like growth factor (IGF)/IGF-binding protein axis. Growth failure can be managed by optimizing nutrition and fluid/electrolyte homeostasis, and overcoming the growth-inhibiting effects of uremia by high-dose recombinant human (rh) GH treatment. A sufficient catch-up growth is one of the determining issues for the overall success of pediatric kidney transplantation (Tx). However, despite satisfactory renal function, spontaneous catch-up growth is often insufficient as glucocorticoid treatment is the main inhibiting factor for longitudinal growth after Tx. In addition, longitudinal growth may be jeopardized by low glomerular filtration rate (GFR) and African American or Hispanic background. Supraphysiological doses of GH and/or IGF-I in vitro and in vivo can partially overcome the growth-inhibiting effects of glucocorticoid treatment. GH-associated increase of leukocyte proliferation and cytotoxicity with stimulated interferon synthesis have been demonstrated. However, it is not clear whether such stimulatory effects on leukocyte function are a transitory or a constant risk factor after organ Tx. Clinical trials of GH in children after renal Tx have suggested a rather moderate or transient effect of rhGH on the immune system, and corticosteroids induce a hyporesponsiveness to the action of GH. As long as corticosteroids are believed to be essential after renal Tx, rhGH should be considered to optimize longitudinal growth in children.

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“…Late steroid withdrawal is still controversial in pediatric kidney transplantation, but has been shown in at least one study [42] that included 40 stable recipients to be safe and successful when under an immunosuppressive maintenance therapy with cyclosporine A and mycophenolate mofetil.…”

Section: Immunosuppressionmentioning

confidence: 98%

Historical review and perspectives in pediatric transplantation

Otte¹

2006

Current Opinion in Organ Transplantation

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Purpose of reviewRecent progress in organ transplantation in children is illustrated by analysis of the most informative papers published during [2005][2006]. Recent findingsThe review focuses on immunosuppression, steroid withdrawal or avoidance, living-related transplantation, long-term survival, drug-related nephrotoxicity, growth, and quality of life in solid organ transplantation. Summary Research on better, more selective, and safer immunosuppression must be pursued as well as the search for surrogate markers of tolerance. Long-term analysis is needed of quality of life beyond 10-15 years after transplantation. Abbreviations cGFR calculated glomerular filtration rate HRQL health-related quality of life IMD inherited metabolic disorder LRLT living-related liver transplantation OLT orthotopic liver transplant PELD Pediatric End-Stage Liver Disease scoring system PTLD posttransplant lymphoproliferative disorder rhGH recombinant human growth hormone UNOS United Network for Organ Sharing ß

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Steroid withdrawal in pediatric and adult renal transplant recipients

Cited by 27 publications

References 36 publications

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

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

Longitudinal growth in children following kidney transplantation: from conservative to pharmacological strategies

Historical review and perspectives in pediatric transplantation

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