Steroid withdrawal in kidney transplant recipients: is it a safe option?
The long-term side effects of lifelong steroid immunosuppression are well documented, therefore, steroid withdrawal (SW) if safe would clearly be of benefit. From 1987-1996, 470 kidney transplants were performed at our institution. During this time period, steroid withdrawal was offered to a select group of patients (n = 43) who were at least 1 year post transplant (27.6 +/- 12.0 months, 15-64 months), had stable graft function and had experienced only mild episodes of rejection in the postoperative period. Informed consent was obtained from all participants. Twenty-five patients were male and 18 were female. The mean age at time of transplantation was 42.4 +/- 14.1 years (17-65 years). There were 28 cadaveric renal transplants (CRT), 10 living related kidney transplants (LRT) and 5 simultaneous kidney-pancreas transplants (SPK). Maintenance immunosuppression in all patients consisted of CSA 3-5 mg/kg, and AZA 1-2 mg/kg. Twenty-nine patients (67%) have remained off steroids with good renal function for 13-59 months (38.3 +/- 11.0). Steroids were restarted in 14/43 (32%) patients 1-36 months post SW (13.3 +/- 11.0 months). Eight of these 14 patients had a rise in creatinine and biopsy proven rejection, 5 of whom responded to reinstitution of steroid immunosuppression, and have stable renal function (CR = 2.0 +/- 0.4) 41-53 months (45 +/- 4.0 months) post SW. Three (7%) patients lost their allograft. One was a SPK recipient who retained good pancreatic function and subsequently received a successful 2nd kidney transplant. The other 2 patients died awaiting retransplantation. Steroids were recommenced in 6/14 patients who did not develop rejection for inability to tolerate CSA/AZA (2), anxiety (2) or recurrent disease (2). In the majority of our patients, (93%) SW did not result in immunologic graft loss. A graft loss of 7% (3) is not significantly different from the expected graft loss in a kidney transplant recipient population over a time period of 9 years. Therefore, we feel that with careful monitoring steroid withdrawal can be safely accomplished in select patients.
Sanfey
H
H
Transplant Division, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
Haussman
G
G
Isaacs
I
I
Ishitani
M
M
Lobo
P
P
McCullough
C
C
Pruett
T
T
D000293:Adolescent; D000328:Adult; D000368:Aged; D001379:Azathioprine / Q000627:therapeutic use; D001706:Biopsy; D002102:Cadaver; D003404:Creatinine / Q000097:blood; D016572:Cyclosporine / Q000627:therapeutic use; D016903:Drug Monitoring; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006084:Graft Rejection / Q000209:etiology / Q000503:physiopathology; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D016030:Kidney Transplantation / Q000502:physiology; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D016035:Pancreas Transplantation; D012086:Reoperation; D012449:Safety; D015996:Survival Rate; D014184:Transplantation, Homologous
D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D003404:Creatinine; D001379:Azathioprine