PREDNISONE WITHDRAWAL IN HLA IDENTICAL AND ONE HAPLOTYPE-MATCHED LIVE-RELATED DONOR AND CADAVER RENAL-TRANSPLANT RECIPIENTS

Prednisone withdrawal was attempted in 121 of 915 renal transplants re cipients between 1967 to 1992. There were 57 males, 64 females. Age ra nge was 21 to 62 (mean 39.2 years). Etiology of renal failure was chro nic glomerulonephritis (54), diabetic nephropathy (36), interstitial d isease (17), hypertensive nephrosclerosis (6), and other (8). Kidney s ource was from HLA-identical living-related donors (LRD) in 54 (Group I), one haplotype-matched LRD in 23 (Group II), and cadaver in 44 (Gro up III). Prior to the introduction of cyclosporin A (CsA) in 1984, pre dnisone withdrawal was attempted only in Group I. After 1984, predniso ne withdrawal was also attempted in patients in Groups II and II, sele cted on the basis of having had no rejection episodes during the six m onths after transplantation. Forty-five patients in Group I were treat ed with azathioprine (Aza) and prednisone, and the remaining patients in Groups I to III were treated with Aza, prednisone and CsA. Mean fol low-up was 93 months (6 to 207). Prednisone was gradually tapered and withdrawn in 94 of 121 patients after a mean period of 22.5 months (9 to 60). In 27 other patients, the prednisone dosage has been tapered t o 5 mg/day or less with the aim of discontinuing the drug. There were seven episodes of acute rejection (3 during taper, and 1 each at 6, 7, 24 and 114 months after prednisone withdrawal); all seven were succes sfully reversed. Four other patients developed chronic vascular reject ion (2 during taper and 2 after withdrawal). Five of the 121 patients died with a functioning graft. There was one graft loss due to chronic rejection. Patient and graft survival at 1, 3, 5 and 10 years was 100 %, 97.4%, 96.2% and 94.1%, and 100%, 97.4% 96.2% and 91.7%, respective ly. Beneficial effects of prednisone withdrawal were: (1.) reduced inc idence of hypertension from 41% to 24%, (P < 0.02); (2.) reduction in total cholesterol from 231 to 197 mg/dl (P < 0.004) and LDL cholestero l 137 to 113 (P < 0.04); (3.) reduction in insulin requirement in diab etic recipients from 64.8 to 50.5 U/day (P < 0.04). There was no signi ficant change in body weight, serum creatinine (pre-withdrawal 1.28, p ost-withdrawal 1.27 mg/dl, respectively) and blood CsA levels pre- and post-prednisone withdrawal. In conclusion, prednisone can be withdraw n safely in selected patients. The long-term results in these patients are extremely good and late complications are minimized.