Steroids in organ transplantation: Immunosuppression and tolerance

Organ transplantation has evolved significantly since the first successful kidney transplant in the 1950s, but corticosteroids remain a mainstay of immunosuppressive therapy. This review addresses the emerging and expanding role of corticosteroids as adjunct therapeutic agents in transplantation with particular emphasis on their immunosuppressive and tolerance inducing properties. The progression of current immunosuppressive strategies, including the combined use of steroids, calcineurin inhibitors, and mTOR inhibitors have also been discussed. The review highlights the mechanisms underlying glucocorticoid activity, including receptor interactions, gene regulation, and modulation of inflammatory responses. The clinical significance of corticosteroids is discussed across different stages of transplant therapy, including induction, long-term maintenance, and management of acute rejection episodes. Special attention is given to their ability to promote immune tolerance by enhancing regulatory T-cell activity, thereby contributing to immune homeostasis and graft survival. Finally, review addresses future perspectives focused on minimizing steroid exposure through more individualized immunosuppressive approaches while evaluating the continuing central role of corticosteroids in the induction of transplant tolerance.