Steroid avoidance or withdrawal in kidney transplantation

Purpose of review Steroid avoidance or early withdrawal in kidney transplantation is supported by recent guidelines, but late steroid withdrawal after the first posttransplant months has been recently discouraged in those guidelines. We have assessed the recent data trying to confirm whether or not these different steroid-sparing strategies are well tolerated. Recent findings Reversible, mild acute rejection rates are increased after steroid avoidance or withdrawal. However, steroid avoidance or early withdrawal is well tolerated in low immunological risk kidney transplant recipients receiving induction with anti-IL2 receptor antibodies or thymoglobulin and a drug regimen based on calcineurin inhibitor and mycophenolate mofetil, at least during 5 years, the longest follow-up reported. In addition, steroid withdrawal after 3-6 months is associated with stable graft function and survival stable up to 3 years after transplantation, the longest follow-up reported. Although clear benefits (cardiovascular and others) are obvious in some observational studies, true benefits in randomized controlled trials remain unclear. Summary Both early and late steroid withdrawals are well tolerated in selected low-risk renal allograft recipients treated with modern potent immunosuppression. More trials with carefully designed outcome measures are needed, especially with other modern combinations, including mTOR inhibitors and/or belatacept.