Steroid withdrawal in liver transplantation: benefits, risks, and unanswered questions

Since the early days of clinical liver transplantation, steroid therapy has constituted the mainstay of maintenance immunosuppression and is still currently combined with cyclosporine or tacrolimus worldwide. Nevertheless, the side effects of long-term steroid administration, particularly diabetes, hypercholesterolemia, arterial hypertension, infections, and bone diseases, including growth retardation in children, have focused the interest on the feasibility of steroid-free immunosuppression. The benefits and the risks of steroid withdrawal (SW) after liver transplantation are overviewed. In adults, early (3 months after transplantation) SW has been validated by several studies, whereas in pediatric recipients, the timing and selection criteria to optimize the risk/benefit ratio of SW still constitute a matter of debate. The identification of the unanswered questions in this field may serve as a framework for future studies to better assess steroid-free immunosuppression after liver transplantation.