Ten-Year Outcome after Rapid Discontinuation of Prednisone in Adult Primary Kidney Transplantation

Abstract

SummaryBackground and objectives Rapid discontinuation of prednisone after kidney transplantation potentially allows for minimization of steroid-related side effects. Although intermediate-term data with rapid discontinuation of prednisone have been promising, concern still exists regarding long-term outcomes. The 10-year experience is reported herein.Design, setting, participants, & measurements Between October 1, 1999 and December 31, 2010, 1241 adult primary kidney transplants (791 living donor and 450 deceased donor) were performed using a protocol in which prednisone is discontinued after postoperative day 5. The 10-year actuarial recipient and graft survival rates and prednisone-related side effects were studied.Results Ten-year actuarial patient survival was 71% for living donor transplants and 62% for deceased donor transplants; 10-year graft survival was 61% for living donor transplants and 51% for deceased donor transplants, and was comparable to 10-year Scientific Registry of Transplant Recipients national data. Ten-year deathcensored graft survival was 79% for living donor transplants and 80% for deceased donor transplants. Ten-year acute rejection rates were 25% for deceased donor transplants and 31% for living donor transplants; 10-year chronic rejection (interstitial fibrosis/tubular atrophy) rates were 39% for deceased donor transplants and 47% for living donor transplants. For nondiabetic recipients of living donor or deceased donor allografts, the incidence of new-onset diabetes was significantly lower than in historical controls on prednisone (P,0.001). We also found significantly reduced rates of cataracts, avascular necrosis, and cytomegalovirus infection in some subgroups.Conclusions Prednisone-related side effects can be minimized in a protocol incorporating rapid discontinuation of prednisone for maintenance immunosuppression. Ten-year patient and graft outcomes remain acceptable.

Kidney Transplantation with Early Corticosteroid Withdrawal

“…The secondary analyses conducted to date raise concerns about the preconception that ECSW regimens would substantially lower fracture risk. [15][16][17][18] Trials by Woodle et al 17 and Rizzari et al 16 found no difference in fracture rates. However, fractures were a secondary outcome, and spine fractures, among the most common types of post-transplant fractures, 4 were not ascertained.…”

“…10,11 Several trials suggested that they are associated with a stabilization of or an increase in areal BMD at the spine and hip. [12][13][14] However, recent data suggest that management with ECSW may result in only minimal 15 or no [16][17][18] protection against fractures. These studies suggest that our understanding of fracture pathogenesis after transplantation is incomplete, that fracture risk with ECSW may be independent of changes in areal BMD measured at the spine and hip, and that ECSW may be associated with abnormalities in bone quality that are not detected by dual energy x-ray absorptiometry (DXA).…”

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“…12 A large single-center retrospective analysis by Rizzari and associates involving 1241 adult primary kidney transplant recipients showed similar patient and graft survival rates at 10 years for rapid steroid discontinuation group compared with historic controls on maintenance steroids. 13 In the subgroup of patients who received deceased-donor kidney transplants, patient and graft survival results were significantly higher in the rapid steroid discontinuation group. There were significant reductions in the incidence of new onset of type 2 diabetes mellitus after transplant, as well as cataracts and avascular necrosis in the rapid steroid discontinuation group.…”

Impact of steroid maintenance on the outcomes in first-time deceased donor kidney transplant recipients: Analysis by induction type

“…A meta-analysis involving 34 studies and 5637 patients showed a small increase in AR rates in steroid avoidance/withdrawal group, without any measurable adverse effect on graft or patient survival, while enjoying significant benefits in terms of CV risk factors [17] . A large single center retrospective analysis involving 1241 primary living and DDK transplant recipients showed similar patient, graft, death-censored graft, and AR free survival rates at 10 years for rapid steroid discontinuation group compared to historic controls on maintenance steroids [18] . All patients received induction with r-ATG and maintenance therapy consisting of a CNI agent along with either MMF or sirolimus.…”