Steroid avoidance or withdrawal for kidney transplant recipients

Pascual, Julio; Zamora, Javier; Galeano, C.; Royuela, Ana; Quereda, C.

doi:10.1002/14651858.cd005632.pub2

Cited by 81 publications

(97 citation statements)

References 205 publications

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“…10 Steroid cessation or avoidance has been associated with reduced cancer incidence, but this has not reached statistical significance in meta-analysis. 50 Regarding other immunosuppressive drugs, we found no association of CNIs with SCC development in this cohort. This is in contrast to the article by Dantal et al 51 in which low-dosage CNI regimens protected from SCC development within 5 years of transplantation.…”

Section: Cd28contrasting

confidence: 52%

Immune Phenotype Predicts Risk for Posttransplantation Squamous Cell Carcinoma

Carroll

Segundo²,

Hollowood³

et al. 2010

Journal of the American Society of Nephrology

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Cutaneous squamous cell cancer (SCC) affects up to 30% of kidney transplant recipients (KTRs) within 10 years of transplantation. There are no reliable clinical tests that predict those who will develop multiple skin cancers. High numbers of regulatory T cells associate with poor prognosis for patients with cancer in the general population, suggesting their potential as a predictive marker of cutaneous SCC in KTRs. We matched KTRs with (n ϭ 65) and without (n ϭ 51) cutaneous SCC for gender, age, and duration of immunosuppression and assessed several risk factors for incident SCC during a median follow-up of 340 days. Greater than 35 peripheral FOXP3 ϩ CD4 ϩ CD127 low regulatory T cells/l, Ͻ100 natural killer cells/l, and previous SCC each significantly associated with increased risk for new cutaneous SCC development (hazard ratio [HR] 2.48 [95% confidence interval (CI) 1.04 to 5.98], HR 5.6 [95% CI 1.31 to 24], and HR 1.33 [95% CI 1.15 to 1.53], respectively). In addition, the ratio of CD8/FOXP3 expression was significantly lower in cutaneous SCC excised from KTRs (n ϭ 25) compared with matched SCC from non-KTRs (n ϭ 25) and associated with development of new cutaneous SCCs. In summary, monitoring components of the immune system can predict development of cutaneous SCC among KTRs.

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Section: Cd28contrasting

confidence: 52%

Immune Phenotype Predicts Risk for Posttransplantation Squamous Cell Carcinoma

Carroll

Segundo²,

Hollowood³

et al. 2010

Journal of the American Society of Nephrology

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“…Cardiovascular risk factors following renal transplant transplant diabetes was similar in all groups, although the number of RTRs who were able to be managed with diet alone was greater in those who had avoided steroids compared to those who were treated conventionally. This is supported by a Cochrane review of 30 RCTs which found that steroidsparing and withdrawal strategies showed benefits in reducing post-transplant diabetes requiring treatment and CV events [78] . They concluded that steroid avoidance and steroid withdrawal strategies in kidney transplantation are not associated with increased mortality or graft loss despite an increase in acute rejection.…”

Section: Diabetes Mellitusmentioning

confidence: 84%

Cardiovascular risk factors following renal transplant

Neale

Smith

2015

WJT

117

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Kidney transplantation is the gold-standard treatment for many patients with end-stage renal disease. Renal transplant recipients (RTRs) remain at an increased risk of fatal and non-fatal cardiovascular (CV) events compared to the general population, although rates are lower than those patients on maintenance haemodialysis. Death with a functioning graft is most commonly due to cardiovascular disease (CVD) and therefore this remains an important therapeutic target to prevent graft failure. Conventional CV risk factors such as diabetes, hypertension and renal dysfunction remain a major influence on CVD in RTRs. However it is now recognised that the morbidity and mortality from CVD are not entirely accounted for by these traditional risk-factors. Immunosuppression medications exert a deleterious effect on many of these well-recognised contributors to CVD and are known to exacerbate the probability of developing diabetes, graft dysfunction and hypertension which can all lead on to CVD. Nontraditional CV risk factors such as inflammation and anaemia have been strongly linked to increased CV events in RTRs and should be considered alongside those which are classified as conventional. This review summarises what is known about risk-factors for CVD in RTRs and how, through identification of those which are modifiable, outcomes can be improved. The overall CV risk in RTRs is likely to be multifactorial and a complex interaction between the multiple traditional and non-traditional factors; further studies are required to determine how these may be modified to enhance survival and quality of life in this unique population. Core tip: Cardiovascular disease (CVD) is the leading cause of death and disability in patients following a renal transplant. Identification of risk factors for CVD and strategies for their improvement are required in order to prevent graft failure in this complex patient

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“…Meta-analyses of randomized controlled trials of steroid withdrawal have demonstrated similar transplant outcomes despite an increased risk for acute rejection with early steroid withdrawal when compared to steroid maintenance. [8][9][10] A registry analysis by Luan and associates showed a reduced risk for graft failure and patient death at 1 and at 4 years in kidney transplant recipients continued on a steroid-free regimen. 11 The 5-year prospective randomized trial by Woodle and associates demonstrated reductions in weight gain, new onset of type 2 diabetes mellitus after transplant, and hypertriglyceridemia in kidney transplant recipients randomized to early steroid withdrawal following antibody induction and calcineurin inhibitor and mycophenolate mofetil maintenance.…”

Section: Discussionmentioning

confidence: 99%

Untitled

2016

Exp Clin Transplant

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Objectives: This study explored the safety of early steroid withdrawal in recipients of expanded criteria deceased-donor kidney transplants. Materials and Methods: Using the Organ Procurement and Transplant Network-United Network of Organ Sharing database, we identified patients who underwent expanded criteria deceased-donor kidney transplant between January 2000 and December 2008 after receiving induction with rabbit-antithymocyte globulin (n = 3717), alemtuzumab (n = 763), or interleukin 2 blocking agent (n = 2600) followed by calcineurin inhibitor and mycophenolate mofetilbased maintenance with and without steroid therapy. Results: Adjusted overall graft survival (hazard ratio 1.32; 95% confidence interval, 1.1-1.56; P = .002) and patient survival (hazard ratio 1.46, 95% confidence interval, 1.16-1.83, P = .001) were inferior, whereas death-censored graft survival (hazard ratio 1.13; 95% confidence interval, 0.87-1.47; P = .35) was similar for chronic steroid maintenance versus early steroid withdrawal groups in rabbit-antithymocyte globulininduced patients. Graft and patient outcomes were similar for chronic steroid maintenance versus early steroid withdrawal groups among alemtuzumab and interleukin 2 blocking agent-induced patients. Among rabbit-antithymocyte globulin-induced patients, adjusted overall graft survival (hazard ratio 1.57; 95% confidence interval, 1.2-2.0; P < .001) and patient survival (hazard ratio 1.5; 95% CI, 1.15-2.1; P = .004) were inferior, whereas death-censored graft survival (hazard ratio 1.5; 95% confidence interval, 0.97-2.43; P = .07) trended inferior for chronic steroid maintenance versus early steroid withdrawal groups in recipients > 60 years old (n = 1729). Conclusions: Our study showed safety of early steroid withdrawal in recipients of expanded criteria deceaseddonor kidney transplants who underwent perioperative induction followed by calcineurin inhibitor and mycophenolate mofetil maintenance. Among rabbitantithymocyte globulin-induced patients, chronic steroid maintenance was associated with inferior graft and patient outcomes, an effect limited to older recipients.

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Steroid avoidance or withdrawal for kidney transplant recipients

Cited by 81 publications

References 205 publications

Immune Phenotype Predicts Risk for Posttransplantation Squamous Cell Carcinoma

Immune Phenotype Predicts Risk for Posttransplantation Squamous Cell Carcinoma

Cardiovascular risk factors following renal transplant

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