Evidence-Based Medicine
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Dec 24, 2016; 6(4): 759-766
Published online Dec 24, 2016. doi: 10.5500/wjt.v6.i4.759
Corticosteroid minimization in renal transplantation: Careful patient selection enables feasibility
Georgios Vlachopanos, Julie M Bridson, Ajay Sharma, Ahmed Halawa
Georgios Vlachopanos, Department of Nephrology, Rethymnon General Hospital, 74100 Rethymnon, Greece
Georgios Vlachopanos, Julie M Bridson, Ajay Sharma, Ahmed Halawa, Faculty of Health and Life Sciences, Institute of Learning and Teaching, University of Liverpool, Liverpool L69 3BX, United Kingdom
Ajay Sharma, Department of Transplantation, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom
Ahmed Halawa, Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
Author contributions: All authors contributed to the conception and design of the review as well as giving final approval of the final version; Vlachopanos G performed the literature review as well as drafting of initial version and subsequent revisions up to final version; Bridson JM, Sharma A and Halawa A provided critical revision and editing of initial and all subsequent versions.
Conflict-of-interest statement: None declared.
Data sharing statement: The manuscript summarizes data as have been reported in published literature to date. There were no new patients studied, and no new data compiled. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Ahmed Halawa, Consultant Transplant Surgeon, Department of Transplantation, Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU, United Kingdom. ahmed.halawa@sth.nhs.uk
Telephone: +44-77-87542128 Fax: +44-11-42714604
Received: July 14, 2016
Peer-review started: July 25, 2016
First decision: September 2, 2016
Revised: October 23, 2016
Accepted: November 16, 2016
Article in press: November 18, 2016
Published online: December 24, 2016
Abstract
AIM

To explore the benefits and harms of corticosteroid (CS) minimization following renal transplantation.

METHODS

CS minimization attempts to improve cardiovascular risk factors (hypertension, diabetes, dyslipidemia), to enhance growth in children, to ameliorate bone disease and to lead to better compliance with immunosuppressive agents. Nevertheless, any benefit must be carefully weighed against the reduction in net immunosuppression and the potential harm to renal allograft function and survival.

RESULTS

Complete CS avoidance or very early withdrawal (i.e., no CS after post-transplant day 7) seems to be associated with better outcomes in comparison with later withdrawal. However, an increased incidence of CS-sensitive acute rejection has been observed with all CS minimization strategies. Among the prerequisites for the safe application of CS minimization protocols are the administration of induction immunosuppression and the inclusion of calcineurin inhibitors in maintenance immunosuppression regimens.

CONCLUSION

Transplant recipients at low immunological risk (primary transplant, low panel reactive antibodies) are thought as optimal candidates for CS minimization. CS avoidance may also be undesirable in patients at risk for glomerulonephritis recurrence or with severe delayed graft function and prolonged cold ischemia time. Thus, CS minimization is not yet ready for implementation in the majority of transplant recipients.

Keywords: Acute rejection, Corticosteroid withdrawal, Corticosteroid minimization, Corticosteroid avoidance, Immunosuppression, Renal transplantation

Core tip: Although corticosteroids have been traditional components of immunosuppressive regimens in renal transplantation, corticosteroid minimization strategies are developed in an attempt to mitigate their many side-effects. The benefit from this approach must be balanced against the risk of acute rejection due to insufficient immunosuppression and the potential harm to allograft survival. We present an overview of these strategies and their impact on clinical outcomes analyzing the key clinical trials performed. Furthermore, we focus on patient selection according to the immunological risk and the induction immunosuppression, the principal factors that determine the success of corticosteroid withdrawal and avoidance protocols.