Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Apr 18, 2021; 11(4): 99-113
Published online Apr 18, 2021. doi: 10.5500/wjt.v11.i4.99
Does steroid-free immunosuppression improve the outcome in kidney transplant recipients compared to conventional protocols?
Ahmed Aref, Ajay Sharma, Ahmed Halawa
Ahmed Aref, Department of Nephrology, Sur hospital, Sur 411, Oman
Ajay Sharma, Department of Transplantation, Royal Liverpool University Hospitals, Liverpool 111, United Kingdom
Ahmed Halawa, Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
Author contributions: Halawa A selected the topics for the work, providing expert advice on our work and the final editing of the manuscript; Sharma A contributed the supervision of the scientific presentation of the data collection together with the quality evaluation of the data presented; Aref A designed the work, collected the data and wrote the manuscript.
Conflict-of-interest statement: There is no conflict of interest to be declared by any of the authors.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Ahmed Halawa, FRCS (Gen Surg), MSc, Surgeon, Department of Transplantation, Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU, United Kingdom.
Received: November 22, 2020
Peer-review started: November 22, 2020
First decision: January 11, 2021
Revised: January 22, 2021
Accepted: March 19, 2021
Article in press: March 19, 2021
Published online: April 18, 2021

Steroids continue to be the cornerstone of immune suppression since the early days of organ transplantation. Steroids are key component of induction protocols, maintenance therapy and in the treatment of various forms of rejection. Prolonged steroid use resulted in significant side effects on almost all the body organs owing to the presence of steroid receptors in most of the mammalian cells. Kidney allograft recipients had to accept the short and long term complications of steroids because of lack of effective alternatives. This situation changed with the intro-duction of newer and more effective immune suppression agents with a relatively more acceptable side effect profile. As a result, the clinicians have been contemplating if it is the time to abandon the unquestionable reliance on maintenance steroids in modern transplantation practice. This review aims to evaluate the safety and efficacy of various steroid-minimization approaches (steroid avoidance, early steroid withdrawal, and late steroid withdrawal) in kidney transplant recipients. A meticulous electronic search was conducted through the available data resources like SCOPUS, MEDLINE, and Liverpool University library e-resources. Relevant articles obtained through our search were included. A total number of 90 articles were eligible to be included in this review [34 randomised controlled trials (RCT) and 56 articles of other research modalities]. All articles were evaluating the safety and efficacy of various steroid-free approaches in comparison to maintenance steroids. We will cover only the RCT articles in this review. If used in right clinical context, steroid-free protocols proved to be comparable to steroid-based maintenance therapy. The appropriate approach should be tailored individually according to each recipient immuno-logical challenges and clinical condition.

Keywords: Kidney transplantation, Steroid free, Immune suppression, Steroid avoidance, Steroid withdrawal, Outcome

Core Tip: Prolonged steroid therapy was associated with many complications that ranged from cosmetic changes to life-threatening increase in cardiovascular risk profile. The utilisation of antibody induction, together with calcineurin inhibitors maintenance immune suppression, had markedly reduced the incidence of acute rejection. The improved rate of acute rejection encouraged different transplant centres to adopt new steroid-free protocols, especially in fragile cases with multiple comorbidities. Variable steroid-free approaches were tried. We aim to explore the safety and efficacy of various steroid-free protocols by comparing each different modality with the conventional triple immune suppression.