When should steroids be withdrawn following kidney transplantation?
The long-term use of steroids is associated with numerous adverse effects, including osteoporosis, new-onset diabetes after transplant, poor wound healing, hypertension, obesity, and dyslipidemia. Patients at lower immunologic risk do well with early steroid withdrawal 3 to 21 days post-transplantation. However, the benefits of early steroid withdrawal may be outweighed in patients at higher immunologic risk, particularly in the black population. Early steroid withdrawal in this group has shown a higher incidence of acute rejection and chronic antibody mediated rejection. There is possibly a subgroup of blacks that could benefit from steroid withdrawal, but this likely is a group with more potent induction therapy and maintenance immunosuppression. This subgroup would also include fewer human leukocyte antigen (HLA) mismatches, living donor, and no delayed graft function. The late withdrawal of steroids has demonstrated conflicting results.
Steroid-free protocols are increasingly used, despite some controversy over their efficacy and safety. Data from the FREEDOM study group showed a higher rate of acute rejection in the steroid-free group, despite no differences in creatinine, glomerular filtration rate, or graft survival compared to the steroid maintenance arm. The steroid-free group had less statin use, weight gain, and anti-hyperglycemic medicine use. The issue of steroid use post-transplantation remains controversial and requires further investigation to identify the optimal strategy. For now, the use of steroids post-transplantation should be individualized, considering a recipient’s comorbidities and overall risk of allograft rejection.