title: A Comparative Effectiveness Analysis of Early Steroid Withdrawal in Black Kidney Transplant Recipients.
abstract: There is continued debate whether early steroid withdrawal is safe to use in high-immunologic risk patients, such as blacks. The goal of this study was to use comparative effectiveness methodology to elucidate the safety of early steroid withdrawal in blacks with kidney transplants.
  
  
  
  Our cohort study used United Network of Organ Sharing data including all adult black kidney transplant recipients from 2000 to 2009 followed through 2014. Propensity score matching was used to equalize baseline risk between continued steroid and early steroid withdrawal groups. Interaction terms were used to assess if the effect of early steroid withdrawal on outcomes varied by baseline and post-transplant factors. Of 26,582 eligible black patients with kidney transplants (5825 [21.9%] with early steroid withdrawal), 5565 patients with early steroid withdrawal were matched to 5565 blacks on continued steroid use.
  
  
  
  Black patients with early steroid withdrawal had similar risk of graft loss (hazard ratio, 0.98; 95% confidence interval, 0.92 to 1.04; P=0.42) and lower risk of death (hazard ratio, 0.91; 95% confidence interval, 0.84 to 0.99; P=0.02), primarily driven by a late mortality advantage (>4 years post-transplant). Delayed graft function, cytolytic induction, tacrolimus, and mycophenolate significantly modified the effect of early steroid withdrawal on outcomes (P<0.05). Acute rejection rates were slightly higher in the continued steroid group (13.0% versus 11.3%, respectively; P<0.01), but this was not associated with graft or patient survival.
  
  
  
  Overall, early steroid withdrawal in black kidney transplant recipients was not associated with graft loss but seemed to be associated with better long-term patient survival. Early steroid withdrawal in blacks not receiving cytolytic induction, tacrolimus, and mycophenolate or those with delayed graft function was associated with higher risk of graft loss and death.
authors.affiliation: Divisions of Transplant Surgery and.|Department of Pharmacy Services and.
authors.forename: David J
authors.initials: DJ
authors.lastname: Taber
authors.affiliation: Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina; and.
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Hunt
authors.affiliation: Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina; and.
authors.forename: Mulugeta
authors.initials: M
authors.lastname: Gebregziabher
authors.affiliation: Transplant Nephrology and.
authors.forename: Titte
authors.initials: T
authors.lastname: Srinivas
authors.affiliation: Divisions of Transplant Surgery and.
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Chavin
authors.affiliation: Divisions of Transplant Surgery and.
authors.forename: Prabhakar K
authors.initials: PK
authors.lastname: Baliga
authors.affiliation: Department of Medicine, Veteran Affairs Health Services Research and Development, Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.
authors.forename: Leonard E
authors.initials: LE
authors.lastname: Egede
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data*; D057186:Comparative Effectiveness Research; D051799:Delayed Graft Function / Q000209:etiology; D005260:Female; D006084:Graft Rejection / Q000209:etiology; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000627:therapeutic use; D013256:Steroids / Q000627:therapeutic use*; D015996:Survival Rate; D016559:Tacrolimus / Q000627:therapeutic use; D013997:Time Factors; D014481:United States; D028761:Withholding Treatment
chemical_list: D007166:Immunosuppressive Agents; D013256:Steroids; D009173:Mycophenolic Acid; D016559:Tacrolimus
keywords: Blacks; Cohort Studies; Immunosuppressive Agents; Propensity Score; Transplant Recipients; United States; acute allograft rejection; adult; chronic allograft failure; delayed graft function; goals; humans; kidney; kidney transplantation; tacrolimus; transplant outcomes; transplantation