Steroid avoidance or withdrawal for kidney transplant recipients

Area of Science:

• Nephrology and Immunology
• Transplantation Medicine
• Clinical Trial Analysis

Background:

• Steroid-sparing strategies aim to minimize steroid-related adverse effects in kidney transplantation.
• Previous concerns about increased rejection risk have been re-evaluated due to improved immunosuppression and declining acute rejection rates.
• This review is an update of previous analyses published in 2009 and 2016.

Purpose of the Study:

• To assess the benefits and harms of steroid withdrawal or avoidance in kidney transplant recipients.
• To provide an updated evidence-based evaluation of steroid-sparing protocols in kidney transplantation.

Main Methods:

• Systematic review and meta-analysis of randomized and quasi-randomized controlled trials.
• Searched multiple databases including Cochrane Kidney and Transplant Register, CENTRAL, MEDLINE, and Embase up to April 29, 2025.
• Included 53 studies involving 8317 adult and pediatric kidney transplant recipients; risk of bias assessed using Cochrane RoB 1 tool.

Main Results:

• Steroid avoidance may reduce death at 1-5 years (low-certainty evidence) but might increase biopsy-proven acute rejection (low-certainty evidence), particularly without tacrolimus, antimetabolite, and induction therapy.
• Steroid avoidance may reduce post-transplant diabetes mellitus (low-certainty evidence) with little to no effect on cardiovascular events or overall infection.
• Evidence for steroid withdrawal showed little to no effect on death, graft loss, acute rejection, diabetes, cardiovascular events, or infection, with low to moderate certainty.

Conclusions:

• Steroid avoidance may reduce patient death at five years post-kidney transplant, with no short-term difference in death or graft loss compared to maintenance.
• While steroid avoidance may increase acute rejection risk, this risk may be mitigated by combination with specific immunosuppressive therapies.
• Steroid avoidance shows a potential benefit in reducing post-transplant diabetes mellitus without significantly impacting cardiovascular events or infection rates.