STEROID WITHDRAWAL IN KIDNEY-TRANSPLANT RECIPIENTS - IS IT A SAFE OPTION

The long-term side effects of lifelong steroid immunosuppression are w ell documented, therefore, steroid withdrawal (SW) if safe would clear ly be of benefit. From 1987-1996, 470 kidney transplants were performe d 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 f unction and had experienced only mild episodes of rejection in the pos toperative period. Informed consent was obtained from all participants . Twenty-five patients were male and 18 were female. The mean age at t ime of transplantation was 42.4+/-14.1 years (17-65 years). There were 28 cadaveric renal transplants (CRT), 10 living related kidney transp lants (LRT) and 5 simultaneous kidney-pancreas transplants (SPK). Main tenance immunosuppression in all patients consisted of CSA 3-5 mg/kg, and AZA 1-2 mg/kg. Twenty-nine patients (67%) have remained off steroi ds with good renal function for 13-59 months (38.3+/-11.0). Steroids w ere 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 biop sy proven rejection, 5 of whom responded to reinstitution of steroid i mmunosuppression, and have stable renal function (CR=2.0+/-0.4) 41-53 months (45+/-4.0 months) post SW. Three (7%) patients lost their allog raft. One was a SPK recipient who retained good pancreatic function an d 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 tolera te 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 per iod of 9 years. Therefore, we feel that with careful monitoring steroi d withdrawal can be safely accomplished in select patients.