Minimization of steroids in kidney transplantation

The goal of steroid minimization trials has been to minimize or eliminate steroid-related side-effects while simultaneously not increasing the rate of acute rejection (AR) and chronic graft loss. Early trials of late steroid withdrawal (> or =3 months post-transplant) were associated with significantly increased AR rates and late graft loss. More recent trials of rapid discontinuation of prednisone (RDP) (< or =7 days post-transplant) have been associated with little or no increase in AR rates and no difference in graft survival (versus maintenance prednisone). Of note, induction therapy appears to be important for success; however, it is not clear if any single maintenance protocol is superior. Intermediate-term follow-up (5-7 years) is now available for some randomized and nonrandomized trials; graft survival and renal function remain excellent. Most of these trials have been done in low immunologic risk recipients, but there are reports of success of RDP in children, black recipients, sensitized recipients, recipients with potentially recurring disease, and kidney-pancreas recipients. Of critical importance, steroid-related side-effects have been minimized. Steroid minimization protocols can clearly be recommended for low-risk patients; additional trials are necessary for those at higher risk. Additional research is also necessary on integrating calcineurin inhibitor minimization with steroid minimization.