Steroid Minimization in Kidney Transplantation: Rationale, Implementation, and Future Directions

Area of Science:

• Nephrology
• Immunology
• Transplantation Medicine

Background:

• Glucocorticoids have been a cornerstone of kidney transplant immunosuppression since the 1960s.
• Long-term glucocorticoid use leads to significant toxicities, impacting patient outcomes.
• Recent advances allow for reduced or eliminated steroid use in select kidney transplant recipients.

Purpose of the Study:

• To review the rationale, evidence, and strategies for steroid minimization and avoidance in kidney transplantation.
• To highlight current practices, patient selection criteria, and controversies surrounding steroid-sparing regimens.
• To discuss future directions for personalized immunosuppression in kidney transplant recipients.

Main Methods:

• Review of existing literature on glucocorticoid use in kidney transplantation.
• Analysis of emerging monitoring tools supporting individualized immunosuppression.
• Examination of current practice patterns and patient selection for steroid-sparing protocols.

Main Results:

• Steroid minimization/avoidance is feasible in selected kidney transplant recipients.
• Advanced monitoring tools (e.g., DSAs, cfDNA, gene expression) facilitate personalized immunosuppression.
• Current practice varies, with ongoing debates regarding optimal patient selection and protocols.

Conclusions:

• Steroid-sparing immunosuppression represents a shift towards personalized medicine in kidney transplantation.
• Careful patient selection and utilization of novel monitoring tools are crucial for successful steroid avoidance.
• Further research is needed to optimize steroid-sparing strategies and address remaining controversies.