Risk of steroid withdrawal in pediatric renal allograft recipients (a 5-year follow-up)

Withdrawal of steroid therapy in renal allograft recipients remains controversial despite the many side effects of this treatment. We have previously presented data on 16 pediatric renal transplant recipients in whom prednisone was withdrawn 6 months or later post-transplantation. To assess the impact of steroid withdrawal, we retrospectively compared this group of patients (Group 1) with a group of 12 patients (Group 2) with renal transplants who continued on prednisone. The groups were compared as to age, sex, ethnicity, source of graft, number of HLA-DR mismatches and incidence of ATN in the immediate postoperative period. The only significant difference was that Group 2 was older. Group 1 had significantly fewer episodes of early acute rejection in the first 6 months post-transplantation than the control group (3/16 vs 8/12, p = 0.009) but nevertheless, without prednisone, had significantly more late acute rejections (11/16 vs 3/12, p = 0.03). Acute rejections occurred as late as 4 years after withdrawal of steroids. Only 5 of the 16 patients in Group 1 have maintained stable graft function without steroids. All of these patients are now alive more than 5 years after steroid withdrawal. In comparing these patients to the other 11, who failed a trial of steroid withdrawal, we found that a serum creatinine of less than 1.7 mg/dl at the time of withdrawal of steroids was predictive of a successful outcome (p = 0.03). In conclusion, withdrawing steroids in pediatric renal allograft recipients has a high risk of late acute rejection and subsequent graft loss, especially for those who have higher baseline creatinine levels.