Short-Term Experience with Early Steroid Withdrawal in African-American Renal Transplant Recipients

Abstract

There are limited data on the results of early steroid withdrawal (ESW) in African-American (AA) renal allograft recipients. We examined short-term transplant outcomes in a retrospective, non-concurrent cohort study of 40 AAs who did not (ESW group), and 33 who did [steroid maintenance (SM) group] receive maintenance steroids after day 4 post-transplant. Patients received thymoglobulin (ATG) induction, mycophenolate mofetil, and tacrolimus or sirolimus. Data were analyzed using survival analysis methods and regression models. Patients in the ESW group were older, had lower current panel reactive antibody and fewer re-transplants, and received fewer doses of ATG. Oneyear graft survival and acute rejection (AR) rates were 100% and 13% in the ESW group and 97% and 15% in the SM group. After controlling for confounders, at 1 year, ESW was not associated with higher risk of graft loss, AR, or worse graft function, but was associated with less weight gain. The SM group had higher cholesterol levels at 3 months and higher risk of posttransplant diabetes mellitus. We did not observe any cases of subclinical rejection. This study suggests that ESW under modern immunosuppression is safe over the short term in at least a subset of AA recipients with risk profiles similar to those studied herein, and could be associated with improved outcomes.

Management of Cardiovascular Disease in Renal Transplant Recipients

“…Mechanisms by which steroids contribute to hypertension include salt retention, weight gain, and mineralocorticoid effect. Improvement in hypertension has been reported in steroid-withdrawal and steroid-avoidance trials (25,26).…”

“…Steroids, even at maintenance dosages, contribute to hyperlipidemia in RTR (46), and improved lipid profiles have been reported in most steroid-free or steroid-withdrawal studies (25,47). Risk for acute rejection with late steroid withdrawal and lack of long-term follow-up in steroid-avoidance trials suggest the need for caution in choosing a steroid-free regimen to improve lipid profile.…”

“…In reports of steroid-avoidance protocols, small decreases in weight gain after transplantation were noticed in some (25) but not all (26) studies. In a carefully controlled study, Painter et al (27) reported that neither weight nor body fat composition was different at 1 yr in patients in a steroid-avoidance protocol versus those who were maintained on steroids.…”

Minimizing Immunosuppression, an Alternative Approach to Reducing Side Effects

“…Woodle et al noted in a multicenter pilot study of early steroid withdrawal in 77 low-risk kidney transplant recipients with TAC/Rapa and antithymocyte globulin induction that the 1-yr biopsy-proven acute rejection rate was 13% and presumptive acute rejection was 10.5% with 100% 1-yr graft and patient survival (56). In an uncontrolled, single-center study involving an inner city population with a high percentage of blacks, Haririan et al report excellent short-term outcomes with early steroid withdrawal using antithymocyte globulin induction, TAC, and Rapa or MMF (65). Although excellent short-term safety in terms of acute rejection risk and graft survival has been reported as initial outcomes in such studies, as longer follow-up is accrued, it appears that a trend to greater attrition of kidney allograft survival exists with the TAC/Rapa combination (66).…”

Defining a Steroid Withdrawal Protocol in a newly established Kidney Transplantation Unit

“…high immunological risk studies, the AR rates were moderate at 13-14% with a remarkably improved graft and patient survival being recorded. However, there is still need for further verifi cation on the consistence of this type of management protocol [44][45][46][47].…”