Early Steroid Withdrawal Versus Steroid Maintenance in Adults Older than 65 Receiving Second Kidney Transplants

The role of steroid maintenance (SM) therapy in older adults with kidney retransplants is uncertain due to the intricate balance between rejection and adverse event risks. We aimed to assess their long-term outcomes, comparing SM versus early steroid withdrawal (ESW).

Retrospective United Network for Organ Sharing registry cohort study. We included adults older than 65 who underwent kidney-only retransplantation between 2010 and 2022, received induction and were discharged on tacrolimus. We evaluated patient death, all-cause allograft failure, and death-censored graft failure (DCGF) among individuals with SM vs ESW at discharge using multivariate Cox proportional hazards models adjusting for several donor, transplant, and recipient covariates. Outcomes were further stratified by calculated panel reactive antibody (cPRA) (<20, 20 to 80, >80).

We included 1858 older adult retransplants (61.3% male, age 68 [interquartile ranges 66 to 71] years), follow-up 2.98 [interquartile ranges 1.00 to 5.28] years). Most (77.9%) received SM, whereas 22.1% had ESW. No statistically significant differences between ESW and SM were observed for patient death (hazard ratios [HR] 1.01, 95% confidence intervals [CI] 0.83 to 1.24), all-cause allograft failure (HR 0.95, 95% CI 0.78 to 1.16), and DCGF (HR 0.97, 95% CI 0.78 to 1.22). In the low cPRA subgroup, SM was associated with increased patient death (HR 1.45, 95% CI 1.01 to 2.08 In those with high cPRA, SM was associated with lower all-cause allograft failure (HR 0.70, 95% CI 0.52 to 0.95) and DCGF (HR 0.66, 95% CI 0.47 to 0.93).

Steroid-maintenance did not alter long-term outcomes in retransplants in adults older than 65. However, SM may be beneficial in high cPRA and harmful in low cPRA subgroups.