Lack of long-term benefits of steroid withdrawal in renal transplant recipients

Sivaraman, P.; Nussbaumer, Gary; Landsberg, David

doi:10.1016/s0272-6386(01)99001-8

Cited by 48 publications

(34 citation statements)

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“…Nevertheless, our results are in line with a recent retrospective study arguing that most metabolic benefits (reduction of body weight, BP, HbA1c, diabetic medication) of prednisolone tapering are seen down to 5 mg/d, whereas no further benefits are observed after SW (36). Moreover, in a cross-sectional study of 77 renal transplant recipients treated with either 0, 5, or 10 mg prednisolone per day, no major differences in body fat mass percentage, lean body mass, waist-to-hip ratio, or substrate (glucose, protein, fat) oxidation rates were observed between groups (37).…”

Section: Comparison With Other Studiessupporting

confidence: 92%

Insulin Resistance after Renal Transplantation

Midtvedt

Hjelmesæth²,

Hartmann³

et al. 2004

Journal of the American Society of Nephrology

166

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Abstract. Cardiovascular disease is a prevalent and serious complication after solid organ transplantation. Treatment with glucocorticoids is associated with increased risk for diabetes mellitus, insulin resistance, weight gain, hypercholesterolemia, and hypertension, all shown to be independent risk factors for cardiovascular disease. We sought to test the hypothesis that tapering of prednisolone (TAP) the first year after renal transplantation improves insulin sensitivity (IS), and to assess the effect of complete steroid withdrawal (SW) on IS in patients on a cyclosporine-based immunosuppressive regimen. All patients (n ϭ 57) completed two consecutive hyperinsulinemic euglycemic glucose clamp procedures, a TAP group (n ϭ 34) and a control group (n ϭ 12) at 3 and 12 mo after transplantation, and a SW group (n ϭ 11) before and 5 mo after SW. The IS index (ISI) was calculated as the glucose disposal rate divided by mean serum insulin the last 60 min of the clamp. In the TAP group, the mean (range) daily prednisolone was reduced from 16 (10 to 30) to 9 (5 to 12.5) mg accompanied by an average increased ISI of 24% (P ϭ 0.008). In contrast, no significant change in ISI was observed in the control group (0%, P ϭ 0.988). In the SW group, withdrawal of 5 mg prednisolone did not influence mean ISI significantly (Ϫ8%, P ϭ 0.206). Lowering daily prednisolone toward 5 mg/d has beneficial effects on insulin action after renal transplantation, but withdrawal of 5 mg prednisolone may not influence IS significantly.

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Section: Comparison With Other Studiessupporting

confidence: 92%

Insulin Resistance after Renal Transplantation

Midtvedt

Hjelmesæth²,

Hartmann³

et al. 2004

Journal of the American Society of Nephrology

166

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“…In the long-term, 59% of kidney recipients and 44% of heart recipients could be maintained completely steroid free. Other studies reported steroid-free maintenance rates in kidney recipients of 49% and 73% (20,21). …”

Section: Cadaver Kidney Recipients With Study Entry In 1st Year After Txmentioning

confidence: 97%

Long-Term Prospective Study of Steroid Withdrawal in Kidney and Heart Transplant Recipients

Opelz

Döhler²,

Laux³

et al. 2005

American Journal of Transplantation

153

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A large prospective study of steroid withdrawal was performed within the framework of the Collaborative Transplant Study to analyze long-term graft and patient outcome in renal and heart transplant recipients. Steroids were withdrawn no earlier than 6 months posttransplantation. A comparison of 7-year outcomes in renal transplant recipients (94% receiving cyclosporine; 97% Caucasian) showed a benefit of steroid withdrawal versus steroid continuation in retrospectively matched controls, for graft survival (81.9% ± 1.8% vs. 75.3% ± 1.2%, p = 0.0001), patient survival (88.8% ± 1.5% vs. 84.3 ± 1.0%; p = 0.0016) and death-censored graft survival (91.8% ± 1.3% vs. 87.9% ± 1.0%: p = 0.0091). Steroid withdrawal was associated with improved graft survival in heart recipients also (76.2% ± 2.4% vs. 66.9% ± 1.7%, p = 0.0008). A total of 58.6% of renal recipients and 44.3% of heart recipients never required steroids during follow up. Rates of acute rejection and renal dysfunction did not differ between steroid-free and steroid-continuation groups. Steroid withdrawal was associated with significantly improved cardiovascular risk factors compared with steroid continuation. Rates of the development of osteoporosis and cataracts did not differ in the entire patient cohort, but were strikingly lower in patients taken off steroids during the first posttransplant year.

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“…Rapid steroid elimination or steroid avoidance protocols are associated with a lower incidence of obesity (45,46). The benefit of late steroid withdrawal (Ն3 mo after transplantation) on weight gain is less clear (47). The potential benefit of steroid reduction or withdrawal must be balanced against the risk for allograft rejection.…”

Section: Obesitymentioning

confidence: 99%

Cardiovascular Disease in Transplant Recipients

Gill¹

2008

Clinical Journal of the American Society of Nephrology

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A cardiovascular disease event in a transplant recipient may be the result of a pretransplantation disease process, a direct effect of immunosuppressant medications, or the result of exposure to a variety of traditional and nontraditional risk factors after transplantation. Although the understanding of posttransplantation cardiovascular disease remains incomplete, there is evidence that the impact of posttransplantation cardiovascular disease has been decreased, through increased attention to this problem. In the absence of controlled studies to guide therapy, this review summarizes treatment of cardiovascular disease risk factors for which there is strong evidence of benefit in the nontransplantation setting, observational evidence of a similar risk in transplant recipients, and evidence that treatment can be safely administered to transplant recipients. Putative risk factors for posttransplantation cardiovascular disease for which the current level of evidence is insufficient to support specific treatment recommendations are also discussed. Potential new strategies to decrease the risk for cardiovascular disease events after transplantation in the future, including aggressive pretransplantation risk reduction, individualized treatments to prevent different types of cardiovascular disease, dedicated efforts to reduce cardiovascular disease events during transitions between dialysis and transplantation, and manipulation of immunosuppressant protocols, are also introduced.Clin J Am Soc Nephrol 3: S29 -S37, 2008. doi: 10.2215/CJN.02690707A lthough increased awareness of cardiovascular disease (CVD) has resulted in a reduction in CVD-related deaths over time (1,2), CVD remains the major known cause of death in transplant recipients (3) and is a significant barrier to improving long-term outcomes in kidney transplantation. The high risk for CVD in transplant recipients is in part explained by the high prevalence of conventional CVD risk factors (e.g., diabetes, hypertension, dyslipidemia) in this patient population; however, a significant portion of CVD risk in transplant recipients is unexplained by these factors (4) and may be related to pretransplantation exposure to chronic kidney disease (CKD)-related risk factors, ongoing exposure to CKD-related risk factors as a result of impaired allograft function, or to transplant-specific risk factors including those related to the use of immunosuppressant medications or infection. Given the relative absence of randomized, controlled trials in transplant recipients, this review summarizes treatments for which there is strong evidence of benefit in the nontransplantation setting, observational evidence of a similar risk in transplant recipients, and evidence that treatment can be safely administered to transplant recipients. The review also summarizes putative risk factors for posttransplantation CVD, for which the current level of evidence is insufficient to support specific treatment recommendations. Finally, the review introduces new strategies to decrease the risk for...

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Lack of long-term benefits of steroid withdrawal in renal transplant recipients

Cited by 48 publications

References 0 publications

Insulin Resistance after Renal Transplantation

Insulin Resistance after Renal Transplantation

Long-Term Prospective Study of Steroid Withdrawal in Kidney and Heart Transplant Recipients

Cardiovascular Disease in Transplant Recipients

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