The Success of Continued Steroid Avoidance After Kidney Transplantation in the US

Abstract

There has been a significant increase in the use of steroid avoidance regimens as initial treatment for kidney transplant recipients. Early results of the effectiveness of this strategy has been mixed with certain prospective trials indicating increased acute rejection but population-based studies indicating similar or better graft survival as compared to steroid maintenance. We conducted a retrospective study of national registry data to evaluate risk factors for discontinuation of steroid avoidance protocols based on patient characteristics and concomitant immunosuppression. We evaluated 84 647 solitary kidney transplant recipients in the US with at least 6 months graft survival including 24 218 initially discharged without maintenance steroids. We utilized logistic models to assess risk factors for new initiation of steroids after initial steroid-avoidance and survival models to describe graft survival for patients after return to steroids. The most prominent risk factors for new initiation of steroids after deceased donor kidney transplantation included African-American race (AOR = 1.32, p < 0.01), retransplants (AOR = 1.81, p < 0.01), highly sensitized recipients (AOR = 1.29, p < 0.01), recipients with Medicaid (AOR = 1.85, p < 0.01), elevated HLA-MM (AOR = 1.26, p < 0.01) and older donor age (AOR = 1.19, p < 0.01). Concomitant medications were also significantly associated with the propensity to newly initiate steroids. Cumulatively the study suggests that both patient characteristics and concomitant medications are strongly associated with the success of steroid avoidance immunosuppressive regimens.

Glomerular Filtration Rate Slopes Have Significantly Improved Among Renal Transplants in the United States

“…Shifts in the use of immunosuppressive regimens with increasing use of steroid avoidance regimens have also occurred (1). Although such regimens are deemed safe in selected patients, they are also associated with an increased risk for acute rejection with uncertain impact on long-term allograft function (2)(3)(4)(5). Calcineurin inhibitor-containing regimens have been associated with excellent graft survival rates.…”

Steroid Avoidance or Withdrawal After Kidney Transplantation: A Balancing Act

“…The identification of risk factors for AR after SAW would be most useful. Recently, Schold et al (16) reported that risk factors for restarting steroids after initial avoidance included African American race, sensitized recipients, patients with Medicaid as primary payer, retransplants, higher functional status recipients, and concomitant immunosuppression. Because this is a retrospective study based on national registry data and initiation of steroids (and not AR) was studied, it is difficult to draw conclusions from this study (16).…”

Role of steroid maintenance in sensitized kidney transplant recipients

“…The impact of these misclassifications on the results likely is minimal since the nondifferential nature of such influence tends to deflate results toward the null [20] . A recent registry analysis identified African American race, retransplants, highly sensitized recipients, recipients with Medicaid, elevated HLA mismatches and older donor age as risk factors for new initiation of steroids in DDK recipients who were initially discharged on an ESW regimen [21] . There were differences in the patterns of induction therapy used in ESW vs CSM groups under each peakPRA category.…”