Steroid-free immunosuppression during and after liver transplantation--a 3-yr follow-up report.
OBJECTIVE
Steroids are traditionally used in liver transplantation as a part of a triple or quadruple immunosuppressive regimen. Steroids act non-specifically and cause multiple side-effects. Most liver transplantation centers reduce the dosage of steroids and eventually withdraw them after various time intervals. A few steroid-free trials have been recently conducted after liver transplantation but long-term data are not yet available. In addition, in these trials steroids were usually given during surgery. We report the long-term (median = 40 months) follow-up data of a prospective pilot study designed to determine whether liver transplantation could be performed with no steroids at all (neither during nor after surgery).


METHODS
Twenty-one consecutive liver transplantations in 20 adult patients between August 1998 and July 1999 were prospectively included in an ab initio steroid-free immunosuppressive protocol. Mean age was 54 yr (40-67 yr). Tacrolimus (through levels, 8-10 ng/mL) and azathioprine (1-2 mg/kg) were started after liver transplantation. Patients were not given steroids during or after liver transplantation except in the event of rejection or in case of tacrolimus or azathioprine toxicity requiring significant dose reduction and/or withdrawal.


RESULTS
There has been no case of primary graft dysfunction or non-function. Eleven of 21 liver transplantations (52%) received no steroids throughout the whole study. Rejection developed in five of 21 liver transplantations (23.5%). These rejections responded to standard i.v. steroids (plus ATG in one patient), followed by an oral steroid taper stopped 3 months after rejection. Steroids were transiently given in six liver transplantations for non-immune reasons: two with tacrolimus-induced neurotoxicity, three cases where azathioprine was discontinued, and one for an allergic reaction; four of these six patients are off steroids at last follow-up. The 3-yr graft and patient survival is 95 and 100%, respectively.


CONCLUSIONS
Steroids are not necessary in more than 50% of liver transplantations. Steroids were transiently needed to treat acute rejection in 23.5% liver transplantations and for toxicity of calcineurin inhibitors or azathioprine or other reason in 28%. Of the patients who received steroids, the majority (70%) was eventually taken off steroids. This prospective single-center pilot study shows that liver transplantation without steroids is feasible and yields no penalty in terms of acute and chronic rejection, immune graft loss, graft function, patient and graft survival.
Pirenne
Jacques
J
Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium. jacques.pirenne@uz.kuleuven.ac.be
Aerts
Raymond
R
Koshiba
Takaaki
T
Van Gelder
Frank
F
Roskams
Tania
T
Schetz
Marie
M
Verhaegen
Marleen
M
Lauwers
Peter
P
Fevery
Johan
J
Nevens
Frederik
F
D001379:Azathioprine / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000627:therapeutic use; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016031:Liver Transplantation; D008776:Methylprednisolone Hemisuccinate / Q000627:therapeutic use; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D016559:Tacrolimus / Q000627:therapeutic use; D013997:Time Factors
D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D008776:Methylprednisolone Hemisuccinate; D001379:Azathioprine; D016559:Tacrolimus