title: Impact of steroid maintenance on the outcomes in first-time deceased donor kidney transplant recipients: Analysis by induction type.
abstract: OBJECTIVE
  To analyze the impact of steroid maintenance on the outcomes in kidney transplant recipients stratified by induction agent received.
  
  
  METHODS
  Patients who underwent first-time deceased donor kidney transplantation between 2000 and 2008 after receiving induction therapy with rabbit-antithymocyte globulin (r-ATG), alemtuzumab or an interleukin-2 receptor blocker (IL-2B) and discharged on a calcineurin inhibitor (CNI)/mycophenolate mofetil (MMF)-regimen along with or without steroids were identified from the Organ Procurement and Transplant Network/United Network of Organ Sharing database. For each induction type, adjusted overall and death-censored graft as well as patient survivals were compared between patients discharged on steroid vs no steroid. Among r-ATG induced patients, analysis was repeated after splitting the group into low and high immune risk groups.
  
  
  RESULTS
  Among the 37217 patients included in the analysis, 17863 received r-ATG (steroid = 13001, no-steroid = 4862), 3028 alemtuzumab (steroid = 852, no-steroid = 2176) and 16326 IL-2B (steroid = 15008, no-steroid = 1318). Adjusted overall graft survival was inferior (HR = 1.16, 95%CI: 1.06-1.27, P = 0.002) with similar death-censored graft survival (HR = 0.99, 95%CI: 0.86-1.14, P = 0.86) for steroid vs no-steroid groups in r-ATG induced patients. Both adjusted overall and death-censored graft survivals for steroid vs no-steroid groups were similar in alemtuzumab (HR = 0.92, 95%CI: 0.73-1.15, P = 0.47 and HR = 0.87, 95%CI: 0.62-1.22, P = 0.43 respectively) and IL-2B (HR = 1.05, 95%CI: 0.91-1.21, P = 0.48 and HR = 0.94, 95%CI: 0.75-1.18, P = 0.60 respectively) induced groups. Adjusted patient survivals were inferior for steroid vs no-steroid groups in r-ATG induced (HR = 1.31, 95%CI: 1.15-1.49, P < 0.001) but similar in alemtuzumab (HR = 1.02, 95%CI: 0.75-1.38, P = 0.92) and IL-2B (HR = 1.17, 95%CI: 0.97-1.40, P = 0.10) induced patients. Among the r-ATG induced group there were 4346 patients in the low immune risk and 13517 patients in the high immune risk group. Adjusted overall graft survivals were inferior for steroid vs no steroid groups in both low immune (HR = 1.34, 95%CI: 1.09-1.64, P = 0.001) and high immune (HR = 1.18, 95%CI: 1.07-1.30, P = 0.005) risk groups. Adjusted death-censored graft survivals for steroid vs no steroid groups were similar in both low (HR = 1.06, 95%CI: 0.78-1.45, P = 0.70) and high (HR = 1.04, 95%CI: 0.98-1.20, P = 0.60) immune risk groups. Adjusted patient survivals were inferior for steroid vs no steroid groups in both low immune (HR = 1.54, 95%CI: 1.18-2.02, P < 0.001) and high immune (HR = 1.32, 95%CI: 1.16-1.51, P = 0.002) risk groups. Overall, there were significantly higher deaths from infections and cardiovascular causes in patients maintained on steroids.
  
  
  CONCLUSIONS
  Our study showed an association between steroid addition to a CNI/MMF-maintenance regimen and increased death with functioning graft in patients receiving r-ATG induction for first-time deceased donor kidney transplantation.
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Kalathil K
authors.initials: KK
authors.lastname: Sureshkumar
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Sabiha M
authors.initials: SM
authors.lastname: Hussain
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Ngoc L
authors.initials: NL
authors.lastname: Thai
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Tina Y
authors.initials: TY
authors.lastname: Ko
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Khaled
authors.initials: K
authors.lastname: Nashar
authors.affiliation: Kalathil K Sureshkumar, Sabiha M Hussain, Tina Y Ko, Khaled Nashar, Richard J Marcus, Divisions of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Marcus
keywords: Graft failure risk; High immune risk; Induction agent; Patient death risk; Steroid maintenance