Published online Apr 18, 2021. doi: 10.5500/wjt.v11.i4.99
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.
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.