Steroid withdrawal in kidney transplant recipients: is it a safe option?

The long-term side effects of lifelong steroid immunosuppression are well documented, therefore, steroid withdrawal (SW) if safe would clearly be of benefit. From 1987-1996, 470 kidney transplants were performed at our institution. During this time period, steroid withdrawal was offered to a select group of patients (n=43) who were at least 1 year post transplant (27.6+/-12.0 months, 15-64 months), had stable graft function and had experienced only mild episodes of rejection in the postoperative period. Informed consent was obtained from all participants. Twenty-five patients were male and 18 were female. The mean age at time of transplantation was 42.4+/-14.1 years (17-65 years). There were 28 cadaveric renal transplants (CRT), 10 living related kidney transplants (LRT) and 5 simultaneous kidney-pancreas transplants (SPK). Maintenance immunosuppression in all patients consisted of CSA 3-5 mg/kg, and AZA 1-2 mg/kg. Twenty-nine patients (67%) have remained off steroids with good renal function for 13-59 months (38.3+/-11.0). Steroids were restarted in 14/43 (32%) patients 1-36 months post SW (13.3+/-11.0 months). Eight of these 14 patients had a rise in creatinine and biopsy proven rejection, 5 of whom responded to reinstitution of steroid immunosuppression, and have stable renal function (CR=2.0+/-0.4) 41-53 months (45+/-4.0 months) post SW. Three (7%) patients lost their allograft. One was a SPK recipient who retained good pancreatic function and subsequently received a successful 2nd kidney transplant. The other 2 patients died awaiting retransplantation. Steroids were recommenced in 6/14 patients who did not develop rejection for inability to tolerate CSA/AZA (2), anxiety (2) or recurrent disease (2). In the majority of our patients, (93%) SW did not result in immunologic graft loss. A graft loss of 7% (3) is not significantly different from the expected graft loss in a kidney transplant recipient population over a time period of 9 years. Therefore, we feel that with careful monitoring steroid withdrawal can be safely accomplished in select patients.