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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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Delucchi Á, Toro L, Alzamora R, Barrientos V, González M, Andaur R, León P, Villanueva F, Galindo M, Las Heras F, Montecino M, Moena D, Lazcano A, Pinto V, Salas P, Reyes ML, Mericq V, Michea L. Glucocorticoids Decrease Longitudinal Bone Growth in Pediatric Kidney Transplant Recipients by Stimulating the FGF23/FGFR3 Signaling Pathway. J Bone Miner Res 2019; 34:1851-1861. [PMID: 31099911 DOI: 10.1002/jbmr.3761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/05/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
Renal transplantation (RTx) is an effective therapy to improve clinical outcomes in pediatric patients with terminal chronic kidney disease. However, chronic immunosuppression with glucocorticoids (GCs) reduces bone growth and BMD. The mechanisms causing GC-induced growth impairment have not been fully clarified. Fibroblast growth factor 23 (FGF23) is a peptide hormone that regulates phosphate homeostasis and bone growth. In pathological conditions, FGF23 excess or abnormal FGF receptors (FGFR) activity leads to bone growth impairment. Experimental data indicate that FGF23 expression is induced by chronic GC exposure. Therefore, we hypothesize that GCs impair bone growth by increasing FGF23 expression, which has direct effects on bone growth plate. In a post hoc analysis of a multicentric randomized clinical trial of prepubertal RTx children treated with early GC withdrawal or chronic GC treatment, we observed that GC withdrawal was associated with improvement in longitudinal growth and BMD, and lower plasma FGF23 levels as compared with a chronic GC group. In prepubertal rats, GC-induced bone growth retardation correlated with increased plasma FGF23 and bone FGF23 expression. Additionally, GC treatment decreased FGFR1 expression whereas it increased FGFR3 expression in mouse tibia explants. The GC-induced bone growth impairment in tibiae explants was prevented by blockade of FGF23 receptors using either a pan-FGFR antagonist (PD173074), a C-terminal FGF23 peptide (FGF23180-205) which blocks the binding of FGF23 to the FGFR-Klotho complex or a specific FGFR3 antagonist (P3). Finally, local administration of PD173074 into the tibia growth plate ameliorated cartilage growth impairment in GC-treated rats. These results show that GC treatment partially reduces longitudinal bone growth via upregulation of FGF23 and FGFR3 expression, thus suggesting that the FGF23/Klotho/FGFR3 axis at the growth plate could be a potential therapeutic target for the management of GC-induced growth impairment in children.
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Affiliation(s)
- Ángela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago, Chile.,Clinica Las Condes, Santiago, Chile
| | - Rodrigo Alzamora
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Nucleus of Ion Channel-Associated Diseases (MiNICAD), Santiago, Chile
| | - Victor Barrientos
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magdalena González
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rodrigo Andaur
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo León
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Francisco Villanueva
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mario Galindo
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
| | - Facundo Las Heras
- Clinica Las Condes, Santiago, Chile.,Department of Anatomic Pathology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martín Montecino
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Daniel Moena
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Andrea Lazcano
- Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile.,Division of Nephrology, Hospital de Niños Roberto del Río, Santiago, Chile
| | - Viola Pinto
- Clinica Las Condes, Santiago, Chile.,Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - Paulina Salas
- Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - María Loreto Reyes
- Pediatric Endocrinology Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Verónica Mericq
- Clinica Las Condes, Santiago, Chile.,Institute of Maternal and Child Research, Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
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Corticosteroid Use and Growth After Pediatric Solid Organ Transplantation: A Systematic Review and Meta-Analysis. Transplantation 2017; 101:694-703. [PMID: 27736823 DOI: 10.1097/tp.0000000000001320] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND A number of corticosteroid minimization and avoidance protocols for post-solid organ transplant have been developed. The study objective was to examine the effect of corticosteroid withdrawal/avoidance on growth and safety parameters in pediatric solid organ transplant recipients. METHODS A systematic review using Medline and Embase was performed. All randomized controlled trials (RCT) and observational studies comparing corticosteroid withdrawal/avoidance to controls receiving corticosteroids in pediatric transplant recipients which reported growth as change in height or final height were included. Two reviewers independently abstracted study data and assessed quality. RESULTS The search yielded 930 records, 14 separate studies involving 1146 patients. Renal RCTs (n = 5) showed that corticosteroid withdrawal/avoidance was associated with a significant increase in growth (mean difference in height standard deviation score [SDS], 0.18; 95% confidence interval [95% CI], 0.07-0.29; P = 0.001) compared with those remaining on steroids. In liver RCTs (n = 2), mean difference in height SDS was -0.20 (95% CI, -1.08 to 0.68; P = 0.66). Results for renal observational studies (n = 5) was 0.34 (95% CI, 0.03-0.65; P = 0.03). The most pronounced effect was seen in prepubertal children with SDS of 0.28 (95% CI, 0.14-0.41; P < 0.0001). In pubertal participants this was not observed (SDS, 0.06; 95% CI, -0.04 to 0.15; P = 0.24). Corticosteroid withdrawal/avoidance was not associated with acute rejection (odds ratio [OR], 0.87; P = 0.63), graft failure (OR, 0.45; P = 0.08), or death (OR, 0.34; P = 0.16) in renal trials. CONCLUSIONS Corticosteroid withdrawal/avoidance in pediatric renal transplantation is associated with a significant improvement in height. Prepubertal patients appeared to have the greatest benefit. Importantly, the improvement in growth was not accompanied by increased rejection or worsening patient/allograft survival in the short term.
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Growth of kidney-transplanted pediatric patients treated with sirolimus. Pediatr Nephrol 2011; 26:961-6. [PMID: 21380626 DOI: 10.1007/s00467-011-1811-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 01/16/2011] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
Abstract
Experimental findings indicate that sirolimus (SRL) inhibits longitudinal growth by mechanisms potentially related to its inhibitory effects on both cell proliferation and expression of vascular endothelial growth factor (VEGF). The aim of this study was to investigate the growth pattern of kidney-transplanted children treated with SRL in a multicenter observational clinical study. Height, change in height SD (Δ height) and growth velocity of pediatric patients with renal transplant were calculated at 0, 6, 12, and 24 months after starting SRL. Controls of kidney-transplanted children not treated with SRL were matched by age, gender, renal function, and dose of corticosteroids. Sixty-eight children (34 SRL, 34 controls) were enrolled in the study. Nephrotoxicity was the most frequent indication to start therapy with SRL. SRL exerted an adverse effect on growth as demonstrated by significantly lower (p < 0.05) growth velocity (cm/year) and smaller change in height SD in the SRL group after 6 (4.08 vs. 6.56 and -0.05 vs. 0.14), 12 (4.44 vs. 6.11 and -0.03 vs. 0.28) and 24 (4.53 vs. 6.03 and -0.04 vs. 0.53) months of treatment. This study suggests that SRL therapy may interfere with growth of kidney-transplanted children. This undesirable effect needs to be taken into account when considering a switch to SRL and confirmed in further prospective trials including larger number of patients.
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