Steroid-free chronic immunosuppression in renal transplantation

Over the past two decades, steroid-free immunosuppression has become more widespread, but improvements in long-term kidney transplant survival have been modest, mandating scrutiny of our chronic regimens.

Current studies and commentary cautiously conclude that steroid-free regimens in low-risk patients seem acceptable for up to 5 years, although most studies are shorter. Patients who will develop chronic rejection cannot be identified prospectively and usually return to steroids. One center continues to report long-term steroid-free results that are comparable to or better than national Scientific Registry of Renal Transplant Recipients (SRTR) outcomes, even with 'older' drugs cyclosporine and azathioprine, reaffirming the need for well designed prospective studies. Some authorities question whether minimal side effects with current regimens justify steroid elimination. In low-risk populations, 'steroid-type' studies probably would suggest no short-term benefit of tacrolimus over cyclosporine, or mycophenolate over azathioprine.

The data justifying steroid-free immunosuppression continue to be suboptimal. A larger question is whether to treat an entire population at medical risk or just the higher-risk subgroup that declares itself in the short term. 'Subgroup therapy' might well produce the same quandaries if applied to other accepted transplant immunosuppression.