title: Steroid avoidance in liver transplantation: meta-analysis and meta-regression of randomized trials.
abstract: Steroid use after liver transplantation (LT) has been associated with diabetes, hypertension, hyperlipidemia, obesity, and hepatitis C (HCV) recurrence. We performed meta-analysis and meta-regression of 30 publications representing 19 randomized trials that compared steroid-free with steroid-based immunosuppression (IS). There were no differences in death, graft loss, and infection. Steroid-free recipients demonstrated a trend toward reduced hypertension [relative risk (RR) 0.84, P = 0.08], and statistically significant decreases in cholesterol (standard mean difference -0.41, P < 0.001) and cytomegalovirus (RR 0.52, P = 0.001). In studies where steroids were replaced by another IS agent, the risks of diabetes (RR 0.29, P < 0.001), rejection (RR 0.68, P = 0.03), and severe rejection (RR 0.37, P = 0.001) were markedly lower in steroid-free arms. In studies in which steroids were not replaced, rejection rates were higher in steroid-free arms (RR 1.31, P = 0.02) and reduction of diabetes was attenuated (RR 0.74, P = 0.2). HCV recurrence was lower with steroid avoidance and, although no individual trial reached statistical significance, meta-analysis demonstrated this important effect (RR 0.90, P = 0.03). However, we emphasize the heterogeneity of trials performed to date and, as such, do not recommend basing clinical guidelines on our conclusions. We believe that a large, multicenter trial will better define the role of steroid-free regimens in LT.
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. dorry@jhmi.edu
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Sozio
authors.forename: Eun Ji
authors.initials: EJ
authors.lastname: Shin
authors.forename: Susanna M
authors.initials: SM
authors.lastname: Nazarian
authors.forename: Hari
authors.initials: H
authors.lastname: Nathan
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Thuluvath
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Cameron
authors.forename: Warren R
authors.initials: WR
authors.lastname: Maley
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016031:Liver Transplantation / Q000276:immunology* / Q000401:mortality; D018579:Patient Selection; D016032:Randomized Controlled Trials as Topic; D012044:Regression Analysis; D012307:Risk Factors; D016019:Survival Analysis
chemical_list: D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents