Cessation of steroids in stable renal transplant patients: the Leuven experience

Because of the major long-term impact of steroids on the quality of life of renal allograft recipients, physicians are attempting to avoid, reduce or eliminate steroids from the immunosuppressive regimen after renal transplantation. In 311 stable renal transplant recipients, transplanted more than one year and with low immunological risk for rejection, an attempt was made to stop steroids. A permanent cessation of steroids succeeded in 274. Cessation of steroids in stable renal transplant patients resulted in a transient rise of serum creatinine over 3 months. This was reflected in a decreased GFR in the first month. A concomitant change in potassium and weight suggested a minor mineralocorticoid deficiency as plausible explanation. After 4 years, serum creatinine again rose slightly; however, this was not reflected in a decreased GFR. This might reflect a metabolic phenomenon rather than immunological one because patients with acute rejection were excluded from this group and also because there was a small rise in weight and blood pressure noted after the second year following cessation of steroids. Only a mild and transient drop in lipids was present after cessation of steroids. Steroid withdrawal was unsuccessful in 12% of patients, and was twice as high in female patients as in males. Adrenal cortical deficiency was the most prominent reason (3%); acute rejection developed in only 5 patients (1.6%) and chronic rejection was documented in only 4 (1.3%). A better graft and patient survival rate and similar renal function, degree of proteinuria and blood pressure 10 years after renal transplantation (and 6 years after cessation of steroids) compared with patients in whom steroids were never stopped, are very promising despite the selection bias. Although longer follow-up is needed to determine whether stopping steroids will result in altered long-term transplant function, these results are reassuring that steroids can be withdrawn in stable renal transplant patients with a low immunological risk in order to diminish the long-term morbidity associated with corticosteroid therapy.