Steroid withdrawal after renal transplantation

Corticosteroid therapy following renal transplantation has been a mainstay in immunosuppression for three decades despite the numerous side effects associated with its use. Because of these, steroid-free immunosuppression has been a persisting goal in clinical transplantation. We have demonstrated that early (within the 1st week of transplantation) steroid withdrawal in renal transplantation, although safe a measured by ultimate graft survival, is associated with an increased rate of severe rejection episodes. Late steroid withdrawal (6 months or later), however, could be successfully achieved in the majority of patients when maintenance therapy consisted of azathioprine and cyclosporine. Immunologic and hematologic consequences included rejection episodes (25%), decreased cyclosporine requirement (higher levels with lower doses), and leukopenia that required azathioprine dosage reduction. More importantly, metabolic consequences included reduced incidence of hypertension, improved glycemic control, and reduced total levels of serum lipids. In regard to the latter, however, nondiabetic patients experienced a rise in their total/HDL cholesterol ratios because of a selective decrease in HDL cholesterol while diabetic patients experienced significant lowering of all lipid levels. All patients looked and felt better after elimination of chronic steroid therapy. The long-term consequences of steroid-free cyclosporine-based immunosuppression on graft survival in renal transplantation are not yet clear.