Health & Medical Organ Transplants & Donation

Prednisone-Free Maintenance Immunosuppression

Prednisone-Free Maintenance Immunosuppression
Concern persists that prednisone-free maintenance immunosuppression in kidney transplant recipients will be associated with an increase in late allograft dysfunction and graft loss. We herein report 5-year follow-up of a trial of prednisone-free maintenance immunosuppression. From October 1, 1999, through January 31, 2005, at our center, 589 kidney transplant recipients were treated with a protocol incorporating discontinuation of their prednisone on postoperative day 6. At 5 years, actuarial patient survival was 91%; graft survival, 84%; death-censored graft survival, 92%; acute rejection-free graft survival, 84% and chronic rejection-free graft survival, 87%. The mean serum creatinine level (±SD) at 1 year was 1.6 ± 0.6; at 5 years, 1.7 ± 0.8. In all, 86% of kidney recipients with functioning grafts remain prednisone-free as of April 30, 2005.

As compared with historical controls, recipients on prednisone-free maintenance immunosuppression had a significantly lower rate of a number of complications, including cataracts (p < 0.001), posttransplant diabetes mellitus (p < 0.001), avascular necrosis (p = 0.001), and fractures (p = 0.004). We conclude that prednisone-related side effects can be minimized in a protocol incorporating prednisone-free maintenance immunosuppression. Five-year graft outcome remains good.

Prednisone is associated with numerous side effects, including hypertension, osteoporosis (and fractures), avascular necrosis, cataracts, mood alterations, posttransplant diabetes, easy bruisability and skin changes. Most kidney transplant recipients, when asked which immunosuppressive agent they would most like to discontinue, name prednisone. Nonetheless, withdrawal of prednisone late posttransplant, even in carefully selected recipients, has resulted in an increased risk of acute rejection and of graft loss.

Recently, we and others have shown that discontinuation of prednisone in the first week posttransplant (or transplantation without any use of prednisone at all) is associated with a low subsequent rate of acute rejection. However, concern persists that such protocols will be associated with an increased risk of late allograft dysfunction and graft loss. In reality, the literature does not substantiate this concern—only one study has reported good early outcome but worse late outcome after prednisone withdrawal. However, to address the ongoing worry, we herein present our 5-year outcome after rapid discontinuation of prednisone in a cohort of kidney transplant recipients.

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