Reasons for long-term use of steroid in primary adult liver transplantation under tacrolimus

Background Tacrolimus is a potent immunosuppressive agent that provides hig her freedom from acute and chronic rejection than cyclosporine after liver transplantation (LTx). Initially, a steroid-free state was observed in abou t 70% of patients at 1 year; this did not change over the next 5 years. The present study identifies the various reasons why the remaining 30% of adul t patients still require steroids even after 5 years after successful LTx. Method. Eight hundred thirty-four consecutive patients who underwent LTx be tween August 1989 and December 1992 were included in this study. Four hundr ed ninety-nine patients were alive in January 1999 and were available for t his study. The dose of steroid and the reason for steroid use were retrospe ctively determined from the clinical records. Results. Three hundred sixty-five patients (73.1%) were off steroid, wherea s 134 patients (26.9%) were receiving prednisone (mean dose was 6.4 +/-3.7 mg/day) at the time of the study. Four hundred and eight-four patients (97% ) were off prednisone at some time after LTx; however, in 119 (23.8%) patie nts, steroids were reintroduced. Fifteen patients (3%) continued to receive prednisone; eight receive prednisone due to reluctance of the local physic ian to withdraw the medication; in five patients, the prednisone was not wi thdrawn because these patients were on cyclosporine; in the remaining two p atients, repeated attempts to withdraw steroid resulted in a rise in liver function test. In the 49 (36.6%) of 119 patients in whom the steroid was re introduced, it was restarted secondary to pathologically proven or clinical ly suspected rejection (group I). In five patients steroid was reintroduced for abnormal liver function after being off immunosuppression for treatmen t of a posttransplantation lymphoproliferative disorder. Six patients were noncompliant with their immunosuppressive medication, and the steroid was r eintroduced to control rejection. Steroids were reintroduced in 30 patients (22.4%) for recurrence of original disease: primary biliary cirrhosis (n=1 9), sclerosing cholangitis (n=6), and autoimmune hepatitis (n=5) (group II) . In 24 patients (20.2%), steroids were reintroduced to lower the dose of t acrolimus secondary to nephrotoxicity. Six of these patients received kidne y transplantation (group III). In 16 patients (13.4%) the steroid was reint roduced for concomitant medical problems, consisting of ulcerative/Crohn's colitis (n=6), adrenal insufficiency (n=5), hematological disorders (n=3), dermatitis (n=1), and rheumatoid arthritis (n=1) (group IV). Conclusion. Ninety-seven percent of patients under tacrolimus were weaned o ff steroid; however, 23.8% required steroid reintroduction for late rejecti on, recurrence of autoimmune process(es), renal impairment, or the concomit ant presence of other medical conditions, Although the use of other immunos uppressive agents may reduce the rate of reintroduction of steroid, long-te rm sustained freedom from steroid may not be possible in all patients under tacrolimus secondary to these conditions.