CORTICOSTEROIDS IN KIDNEY-TRANSPLANT RECIPIENTS - SAFETY ISSUES AND TIMING OF DISCONTINUATION

Corticosteroids have played a key role in the immunosuppression of org an transplantation. Unfortunately, the extensive use of these agents h as resulted in disabling and life-threatening adverse effects in many patients. The advent of concomitant corticosteroid/cyclosporin regimen s has allowed a reduction in the dosages of steroids administered, yet steroid-induced morbidity is still a major problem in many cyclospori n-treated renal transplant patients. After favourable initial experien ces with cyclosporin monotherapy, several attempts at steroid-free imm unosuppression in renal transplant patients have been undertaken, eith er by not starting steroids after transplantation or by stopping stero ids in patients with stable graft function. Most controlled and uncont rolled trials showed that with either strategy short term graft surviv al was similar with or without steroids, but acute rejection was more frequent in patients not taking steroids. The percentage of patients w ho could be maintained steroid-free ranged from 28 to 94%, and was hig her in patients who stopped steroids later than in those never receivi ng them. Little information is available about long term follow-up of these patients. Some studies reported late attrition of renal function in patients not taking steroids, while others reported a favourable o utcome even in the long term. Steroid-free immunosuppression is feasib le in renal transplant patients, but it requires careful monitoring of renal function and cyclosporin dosage. This strategy is particularly indicated in patients at high risk of cardiovascular disease or steroi d-related complications, and in children. Nevertheless, several issues need to be better elucidated by further studies, namely the long term outcome of steroid-free immunosuppression, the advantages and disadva ntages of steroid avoidance versus steroid withdrawal, and the criteri a for selecting patients.