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Chukwu CA, Spiers HV, Middleton R, Kalra PA, Asderakis A, Rao A, Augustine T. Alemtuzumab in renal transplantation. Reviews of literature and usage in the United Kingdom. Transplant Rev (Orlando) 2022; 36:100686. [DOI: 10.1016/j.trre.2022.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
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2
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Thymoglobulin versus Alemtuzumab versus Basiliximab Kidney Transplantation from Donors After Circulatory Death. Kidney Int Rep 2022; 7:732-740. [PMID: 35497810 PMCID: PMC9039467 DOI: 10.1016/j.ekir.2022.01.1042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The Campath, Calcineurin inhibitor (CNI) reduction, and Chronic allograft nephropathy (3C), a study comparing alemtuzumab versus basiliximab induction immunosuppression in kidney transplants, has found lower acute rejection rate with alemtuzumab but same graft survival. The aim of the current study is to evaluate the effect of induction immunosuppression (thymoglobulin, alemtuzumab, basiliximab) on the outcome of kidneys of donors after circulatory death (DCD). Methods Data of the 274 DCD patients of the 3C obtained from the sponsor were compounded with the 140 DCD patients who received thymoglobulin in a single center with the same entry criteria as the 3C, giving 414 patients on 3 induction regimes. Results There were more male donors (P < 0.05) and human leukocyte antigen and DR mismatched patients in the thymoglobulin group (P < 0.001). Death-censored graft survival at 6 months was 98.6% in the thymoglobulin, 95.5% in the alemtuzumab (P = 0.08), and 95.7% in the basiliximab group (P = 0.09) and at 2 years 97.9% versus 94.8% (P = 0.13, hazard ratio [HR] 2.8, 95% CI 0.7–10.9) versus 94.3% (P = 0.06, HR 3.5, 95% CI 0.9–13.6), respectively. The 2-year overall graft survival was 95% in the thymoglobulin versus 88% in the alemtuzumab (unadjusted P = 0.038, adjusted HR 2.4, 95% CI 0.99–5.9) and 91.4% in the basiliximab group (P = 0.21). The 2-year patient survival was numerically less in the alemtuzumab compared with the thymoglobulin group (91.8% vs. 97.1%, P = 0.052, HR 2.90, 95% CI 0.93–9.2). Acute rejection was 17% in the basiliximab, 4.3% in the thymoglobulin, and 6% in the alemtuzumab group (P < 0.001). Conclusion In DCD transplants, thymoglobulin induction may provide advantage over alemtuzumab in patient survival and the same advantage as alemtuzumab over basiliximab in terms of acute rejection. Differing maintenance immunosuppression may contribute to the difference found.
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3
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Sabah TK, Khalid U, Ilham MA, Ablorsu E, Szabo L, Griffin S, Chavez R, Asderakis A. Induction with ATG in DCD kidney transplantation; efficacy and relation of dose and cell markers on delayed graft function and renal function. Transpl Immunol 2021; 66:101388. [PMID: 33775865 DOI: 10.1016/j.trim.2021.101388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
AIM We aimed to analyse the efficacy of the Thymoglobulin dose used for induction in controlled DCD kidneys, and its initial impact on blood cell and CD3 count, as predictors of efficacy. METHODS 140 DCD patients who received ATG induction, were analysed. Intended dose was 1.25 mg/kg/day over 5 days, rounded to nearest 25 mg and not exceeding 125 mg/dose. Outcomes included the total dose in relation with rejection, DGF, graft survival, eGFR. The cell count response to ATG was assessed as predictors of outcome. RESULTS Graft survival, was 96.2%, 92.4%, 85% at 1, 3 and 5 years. Rejection was 7% at 1 year and associated with eGFR at 3 (p = 0.003) and 5 years. ATG dose was not predictive of rejection but was associated with the day5 leucocyte and lymphocyte count (p < 0.001) and negatively with DGF (p = 0.05). In 31 patients day3 CD3 count was available and it was associated with rejection (p = 0.002), less DGF (p = 0.09), and 3 years eGFR (p = 0.01). CONCLUSION Thymoglobulin provides excellent results in DCD kidneys that do not significantly differ with small dose variations. In higher doses it reduces DGF. Lymphocytes and CD3 count, may be useful surrogate markers of efficacy and outcome.
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Affiliation(s)
- Tarique Karim Sabah
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Usman Khalid
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Mohamed Adel Ilham
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Elijah Ablorsu
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Laszlo Szabo
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Sian Griffin
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Rafael Chavez
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - Argiris Asderakis
- Cardiff Transplant Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
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4
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Bae S, Garonzik-Wang JM, Massie AB, McAdams-DeMarco MA, Coresh J, Segev DL. Inconsistencies in the association of clinical factors with the choice of early steroid withdrawal across kidney transplant centers: A national registry study. Clin Transplant 2021; 35:e14176. [PMID: 33259086 PMCID: PMC8284554 DOI: 10.1111/ctr.14176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Approximately 30% of kidney transplant recipients undergo early steroid withdrawal (ESW) for maintenance immunosuppression. However, there is no consensus on which patients are suitable for ESW, and transplant centers may disagree on how various clinical factors characterize individual recipients' suitability for ESW. METHODS To examine center-level variation in the association of clinical factors with the choice of ESW, we studied 206 544 kidney transplant recipients from 278 centers in 2002-2017 using SRTR data. We conducted multi-level logistic regressions to characterize the association of clinical factors with the choice of ESW at each transplant center. RESULTS The association of clinical factors with the choice of ESW varied substantially across centers. We found particularly greater inconsistency in recipient age, PRA, re-transplantation, living/deceased donor, post-transplant length of stay, and delayed graft function. For example, across the entire population, re-transplantation was associated with lower odds of ESW (population odds ratio = 0.35 0.400.46 ). When estimated at each center, this odds ratio was significantly lower than the population odds ratio at 48 (17.3%) centers and significantly higher at 28 (10.1%) centers. CONCLUSIONS We have observed apparent inconsistencies across transplant centers in the practice of tailoring ESW to the recipient's risk profile. Standardized guidelines for ESW tailoring are needed.
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Affiliation(s)
- Sunjae Bae
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Allan B Massie
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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5
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Ahmad N, Khan TFT, Nadeem N, Fourtounas K. Steroid-Sparing and Steroid-Based Immunosuppression in Kidney Transplant: Is There a Difference in Outcomes and Recipient Comorbidities? EXP CLIN TRANSPLANT 2020; 18:572-576. [DOI: 10.6002/ect.2020.0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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6
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Bae S, Garonzik Wang JM, Massie AB, Jackson KR, McAdams-DeMarco MA, Brennan DC, Lentine KL, Coresh J, Segev DL. Early Steroid Withdrawal in Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function. J Am Soc Nephrol 2019; 31:175-185. [PMID: 31852720 DOI: 10.1681/asn.2019040416] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/10/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Early steroid withdrawal (ESW) is associated with acceptable outcomes in kidney transplant (KT) recipients. Recipients with delayed graft function (DGF), however, often have a suboptimal allograft milieu, which may alter the risk/benefit equation for ESW. This may contribute to varying practices across transplant centers. METHODS Using the Scientific Registry of Transplant Recipients, we studied 110,019 adult deceased-donor KT recipients between 2005 and 2017. We characterized the association of DGF with the use of ESW versus continued steroid maintenance across KT centers, and quantified the association of ESW with acute rejection, graft failure, and mortality using multivariable logistic and Cox regression with DGF-ESW interaction terms. RESULTS Overall 29.2% of KT recipients underwent ESW. Recipients with DGF had lower odds of ESW (aOR=0.600.670.75). The strength of this association varied across 261 KT centers, with center-specific aOR of <0.5 at 31 (11.9%) and >1.0 at 22 (8.4%) centers. ESW was associated with benefits and harms among recipients with immediate graft function (IGF), but only with harms among recipients with DGF. ESW was associated with increased acute rejection (aOR=1.091.161.23), slightly increased graft failure (aHR=1.011.061.12), but decreased mortality (aHR=0.860.890.93) among recipients with IGF. Among recipients with DGF, ESW was associated with a similar increase in rejection (aOR=1.12; 95% CI, 1.02 to 1.23), a more pronounced increase in graft failure (aHR=1.16; 95% CI, 1.08 to 1.26), and no improvement in mortality (aHR=1.00; 95% CI, 0.94 to 1.07). DGF-ESW interaction was statistically significant for graft failure (P=0.04) and mortality (P=0.003), but not for rejection (P=0.6). CONCLUSIONS KT centers in the United States use ESW inconsistently in recipients with DGF. Our findings suggest ESW may lead to worse KT outcomes in recipients with DGF.
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Affiliation(s)
- Sunjae Bae
- Departments of Epidemiology and.,Departments of Surgery and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | | | - Allan B Massie
- Departments of Epidemiology and.,Departments of Surgery and
| | | | | | - Daniel C Brennan
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri
| | - Josef Coresh
- Departments of Epidemiology and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland.,Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Dorry L Segev
- Departments of Epidemiology and .,Departments of Surgery and
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7
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Vock DM, Matas AJ. Rapid discontinuation of prednisone in kidney transplant recipients from at-risk subgroups: an OPTN/SRTR analysis. Transpl Int 2019; 33:181-201. [PMID: 31557340 DOI: 10.1111/tri.13530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/30/2019] [Accepted: 09/19/2019] [Indexed: 12/23/2022]
Abstract
Although rapid discontinuation of prednisone (RDP) after kidney transplantation has been successful in low-risk recipients, there is concern about RDP use in recipients at increased risk for rejection or recurrent disease. Using SRTR, we compared outcomes for RDP versus maintenance prednisone-treated recipients for all adult 1st and 2nd transplants (n = 169 479) and the following 1st transplant subgroups: African American (AA); highly sensitized; those with a potentially recurrent disease; and pediatric recipients. For all adult 1st LD and DD transplants, RDP was associated with better patient and graft survival. For all LD subgroups, RDP and maintenance prednisone were associated with similar patient, graft, and death-censored (DC) graft survival. For 1st transplant DD subgroups, RDP was associated with better patient survival in AA, those with potentially recurrent disease, and pediatric recipients; graft survival with RDP was better in AAs. For adult 2nd DD transplants, RDP was associated with worse DC-graft survival. Importantly, for all differences, the effect size was small. With the exception of 2nd DD transplants, RDP protocols can be used without decreasing patient or graft survival for subgroups of 1st DD and LD kidney transplant recipients and for 2nd LD transplant recipients, at increased risk of rejection or recurrent disease.
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Affiliation(s)
- David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
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8
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Bahmani B, Uehara M, Jiang L, Ordikhani F, Banouni N, Ichimura T, Solhjou Z, Furtmüller GJ, Brandacher G, Alvarez D, von Andrian UH, Uchimura K, Xu Q, Vohra I, Yilmam OA, Haik Y, Azzi J, Kasinath V, Bromberg JS, McGrath MM, Abdi R. Targeted delivery of immune therapeutics to lymph nodes prolongs cardiac allograft survival. J Clin Invest 2018; 128:4770-4786. [PMID: 30277476 PMCID: PMC6205374 DOI: 10.1172/jci120923] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/21/2018] [Indexed: 12/12/2022] Open
Abstract
The targeted delivery of therapeutic drugs to lymph nodes (LNs) provides an unprecedented opportunity to improve the outcomes of transplantation and immune-mediated diseases. The high endothelial venule is a specialized segment of LN vasculature that uniquely expresses peripheral node addressin (PNAd) molecules. PNAd is recognized by MECA79 mAb. We previously generated a MECA79 mAb-coated microparticle (MP) that carries tacrolimus. Although this MP trafficked to LNs, it demonstrated limited therapeutic efficacy in our transplant model. Here, we have synthesized a nanoparticle (NP) as a carrier of anti-CD3, and optimized the conjugation strategy to coat the NP surface with MECA79 mAb (MECA79-anti-CD3-NP) to enhance LN accumulation. As compared with nonconjugated NPs, a significantly higher quantity of MECA79-NPs accumulated in the draining lymph node (DLN). Many MECA79-NPs underwent internalization by T cells and dendritic cells within the LNs. Short-term treatment of murine cardiac allograft recipients with MECA79-anti-CD3-NP resulted in significantly prolonged allograft survival in comparison with the control groups. Prolonged graft survival following treatment with MECA79-anti-CD3-NP was characterized by a significant increase in intragraft and DLN Treg populations. Treg depletion abrogated the prolongation of heart allograft survival. We believe this targeted approach of drug delivery could redefine the methods of administering immune therapeutics in transplantation.
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Affiliation(s)
- Baharak Bahmani
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mayuko Uehara
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Liwei Jiang
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Farideh Ordikhani
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Naima Banouni
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takaharu Ichimura
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zhabiz Solhjou
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Georg J Furtmüller
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Alvarez
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ulrich H von Andrian
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenji Uchimura
- Unite de Glycobiologie Structurale et Fonctionnelle, UMR 8576 CNRS, Universite de Lille 1, Villeneuve d'Ascq, France
| | - Qiaobing Xu
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, USA
| | - Ishaan Vohra
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Osman A Yilmam
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yousef Haik
- College of Science and Engineering, Hamad bin Khalifa University, Doha, Qatar
| | - Jamil Azzi
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivek Kasinath
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan S Bromberg
- Department of Surgery and Microbiology and Immunobiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Martina M McGrath
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Abdi
- Transplantation Research Center and.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Does Rabbit Antithymocyte Globulin (Thymoglobuline®) Have a Role in Avoiding Delayed Graft Function in the Modern Era of Kidney Transplantation? J Transplant 2018; 2018:4524837. [PMID: 30112193 PMCID: PMC6077603 DOI: 10.1155/2018/4524837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
Delayed graft function (DGF) increases the risk of graft loss by up to 40%, and recent developments in kidney donation have increased the risk of its occurrence. Lowering the risk of DGF, however, is challenging due to a complicated etiology in which ischemia-reperfusion injury (IRI) leads to acute tubular necrosis. Among various strategies explored, the choice of induction therapy is one consideration. Rabbit antithymocyte globulin (rATG [Thymoglobuline]) has complex immunomodulatory effects that are relevant to DGF. In addition to a rapid and profound T-cell depletion, rATG inhibits leukocyte migration and adhesion. Experimental studies of rATG have demonstrated attenuated IRI-related tissue damage in reperfused tissues, consistent with histological evidence from transplant recipients. Starting rATG intraoperatively instead of postoperatively can improve kidney graft function and reduce the incidence of DGF. rATG is effective in preventing acute rejection in kidney transplant recipients at high immunological risk, supporting delayed calcineurin inhibitor (CNI) introduction which protects the graft from early insults. A reduced rate of DGF has been reported with rATG (started intraoperatively) and delayed CNI therapy compared to IL-2RA induction with immediate CNI in patients at high immunological risk, but not in lower-risk patients. Overall, induction with rATG induction is the preferred choice for supporting delayed introduction of CNI therapy to avoid DGF in high-risk patients but shows no benefit versus IL-2RA in lower-risk individuals. Evidence is growing that intraoperative rATG ameliorates IRI, and it seems reasonable to routinely start rATG before reperfusion.
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10
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Haller MC, Royuela A, Nagler EV, Pascual J, Webster AC. Steroid avoidance or withdrawal for kidney transplant recipients. Cochrane Database Syst Rev 2016; 2016:CD005632. [PMID: 27546100 PMCID: PMC8520739 DOI: 10.1002/14651858.cd005632.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Steroid-sparing strategies have been attempted in recent decades to avoid morbidity from long-term steroid intake among kidney transplant recipients. Previous systematic reviews of steroid withdrawal after kidney transplantation have shown a significant increase in acute rejection. There are various protocols to withdraw steroids after kidney transplantation and their possible benefits or harms are subject to systematic review. This is an update of a review first published in 2009. OBJECTIVES To evaluate the benefits and harms of steroid withdrawal or avoidance for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 15 February 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA All randomised and quasi-randomised controlled trials (RCTs) in which steroids were avoided or withdrawn at any time point after kidney transplantation were included. DATA COLLECTION AND ANALYSIS Assessment of risk of bias and data extraction was performed by two authors independently and disagreement resolved by discussion. Statistical analyses were performed using the random-effects model and dichotomous outcomes were reported as relative risk (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals. MAIN RESULTS We included 48 studies (224 reports) that involved 7803 randomised participants. Of these, three studies were conducted in children (346 participants). The 2009 review included 30 studies (94 reports, 5949 participants). Risk of bias was assessed as low for sequence generation in 19 studies and allocation concealment in 14 studies. Incomplete outcome data were adequately addressed in 22 studies and 37 were free of selective reporting.The 48 included studies evaluated three different comparisons: steroid avoidance or withdrawal compared with steroid maintenance, and steroid avoidance compared with steroid withdrawal. For the adult studies there was no significant difference in patient mortality either in studies comparing steroid withdrawal versus steroid maintenance (10 studies, 1913 participants, death at one year post transplantation: RR 0.68, 95% CI 0.36 to 1.30) or in studies comparing steroid avoidance versus steroid maintenance (10 studies, 1462 participants, death at one year after transplantation: RR 0.96, 95% CI 0.52 to 1.80). Similarly no significant difference in graft loss was found comparing steroid withdrawal versus steroid maintenance (8 studies, 1817 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.17, 95% CI 0.72 to 1.92) and comparing steroid avoidance versus steroid maintenance (7 studies, 1211 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.09, 95% CI 0.64 to 1.86). The risk of acute rejection significantly increased in patients treated with steroids for less than 14 days after transplantation (7 studies, 835 participants: RR 1.58, 95% CI 1.08 to 2.30) and in patients who were withdrawn from steroids at a later time point after transplantation (10 studies, 1913 participants, RR 1.77, 95% CI 1.20 to 2.61). There was no evidence to suggest a difference in harmful events, such as infection and malignancy, in adult kidney transplant recipients. The effect of steroid withdrawal in children is unclear. AUTHORS' CONCLUSIONS This updated review increases the evidence that steroid avoidance and withdrawal after kidney transplantation significantly increase the risk of acute rejection. There was no evidence to suggest a difference in patient mortality or graft loss up to five year after transplantation, but long-term consequences of steroid avoidance and withdrawal remain unclear until today, because prospective long-term studies have not been conducted.
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Affiliation(s)
- Maria C Haller
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Krankenhaus Elisabethinen LinzDepartment for Internal Medicine III, Nephrology & Hypertension Diseases, Transplantation Medicine & RheumatologyFadingerstrasse 1LinzAustria4040
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
| | - Ana Royuela
- Hospital Ramon y CajalCIBER Epidemiologia y Salud Publica (CIBERESP)Ctra. Colmenar km, 9.1MadridSpain28047
- Instituto de Investigación Puerta de Hierro (IDIPHIM)Clinical Biostatistics UnitC/ Joaquín Rodrigo, 2Edif. Laboratorio. Planta 0.MajadahondaMadridSpain28222
| | - Evi V Nagler
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
- Ghent University HospitalRenal Division, Department of Internal MedicineDe Pintelaan 185GhentBelgium9000
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaSpain08003
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Cantarovich D, Rostaing L, Kamar N, Ducloux D, Saint-Hillier Y, Mourad G, Garrigue V, Wolf P, Ellero B, Cassuto E, Albano L, Völp A, Soulillou JP. Early corticosteroid avoidance in kidney transplant recipients receiving ATG-F induction: 5-year actual results of a prospective and randomized study. Am J Transplant 2014; 14:2556-64. [PMID: 25243534 DOI: 10.1111/ajt.12866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/05/2014] [Accepted: 06/15/2014] [Indexed: 01/25/2023]
Abstract
One hundred ninety-seven patients received anti-T-lymphocyte globulins Fresenius, mycophenolate mofetil and delayed cyclosporine, and were randomized to ≥6-month corticosteroids (+CS; n=99) or no CS (-CS; n=98). One- and five-year actual graft survival (censored for death) was 93.2% and 86.4% in the +CS group versus 94.9% and 89.8% in the -CS group (5-year follow-up, p=0.487). Freedom from clinical rejection was 86.9% and 81.8% versus 74.5% and 74.5% (p=0.144), respectively, at 1 and 5 years; 5-year freedom from biopsy-proven rejection was 88.9% versus 83.7% (p=0.227). More late first rejections occurred in the +CS group. Significantly lower 5-year graft survival in patients experiencing rejection was observed for +CS (55.6% vs. 92.0%; p=0.005) with 8/18 versus 2/25 graft losses. Renal function at 5 years was stable and comparable (median serum creatinine, 159 vs. 145 µmol/L; creatinine clearance, 53.5 vs. 56.6 mL/min). More +CS patients developed diabetes, dyslipidemia and malignancies. Rejections in -CS patients occurred early after transplantation and did not impair long-term renal function. In patients receiving CS, rejections occurred later and with a higher risk for subsequent graft failure. A similar and not inferior 5-year efficacy profile and a reduced morbidity were observed in CS-free patients compared to patients who received CS for at least 6 months.
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Affiliation(s)
- D Cantarovich
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Centre Hospitalier et Universitaire de Nantes, Nantes, France
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Immunology of Transplant Protocols. CURRENT OTORHINOLARYNGOLOGY REPORTS 2014. [DOI: 10.1007/s40136-014-0057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Opelz G, Döhler B. Association between steroid dosage and death with a functioning graft after kidney transplantation. Am J Transplant 2013; 13:2096-105. [PMID: 23750878 DOI: 10.1111/ajt.12313] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/17/2013] [Accepted: 04/23/2013] [Indexed: 01/25/2023]
Abstract
Death with a functioning graft remains a major challenge following kidney transplantation. Steroid dosing may be a modifiable risk factor. Collaborative Transplant Study (CTS) data were analyzed to assess the relationship between long-term steroid dose and death with function during years 2-5 posttransplant in 41 953 adult recipients of a deceased-donor kidney transplant during 1995-2010. Steroid dose at year 1 correlated significantly with death with function overall, and with death due to cardiovascular disease or infection (all p < 0.001). In patients with optimal graft function (serum creatinine <130 µmol/L) and no anti-rejection treatment during (a) year 1 (b) years 1 and 2, these significant associations remained (all p < 0.001). The center-specific incidence of steroid withdrawal during year 2 showed a significant inverse association with death due to cardiovascular disease (p < 0.001) or infection (p < 0.001) overall, and within the subpopulation with good graft function and no rejection during year 1 (p = 0.002 and p < 0.001, respectively). Maintenance steroid dose shows a highly significant association with death with a functioning graft caused by cardiovascular disease or infection during years 2-5 after kidney transplantation, even in patients with good graft outcomes in whom steroid treatment would appear to be unnecessary.
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Affiliation(s)
- G Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.
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Cantarovich D, Hodemon-Corne B, Trébern-Launay K, Giral M, Foucher Y, Dantan E. Early Steroid Withdrawal Compared With Steroid Avoidance Correlates With Graft Failure Among Kidney Transplant Recipients With an History of Diabetes. Transplant Proc 2013; 45:1497-502. [DOI: 10.1016/j.transproceed.2012.10.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/30/2012] [Indexed: 11/28/2022]
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Zhang X, Huang H, Han S, Fu S, Wang L. Is it safe to withdraw steroids within seven days of renal transplantation? Clin Transplant 2012; 27:1-8. [PMID: 23072524 DOI: 10.1111/ctr.12015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND The safety of very early steroid withdrawal (VESW) in renal transplant recipients remains unclear. METHODS Literature searches for all randomized controlled trials comparing VESW with steroid maintenance regimens were performed using MEDLINE, EMBASE, and the Cochrane Library. Quality assessment was performed in each trial. Meta-analyses were performed to demonstrate the pooled effects of relative risk (RR) and weighted mean difference with 95% confidence intervals (CI). RESULTS A total of 3520 participants from 15 RCTs were included. VESW regimen increased the incidence of acute rejection (AR) over controls (RR = 1.46, CI = 1.20-1.79, p = 0.04). Subsequent analysis demonstrated that such difference lost significance in patients receiving tacrolimus (p = 0.16), but remained significant in patients with cyclosporin (p < 0.00001). The increased AR episodes were predominantly mild. VESW was associated with an increased incidence of delayed graft function (DGF) when steroids were withdrawn within three d post-transplantation. Cardiovascular risk factors, including incidence of new onset diabetes and total cholesterol, were significantly reduced under VESW regimen. CONCLUSIONS It is safe and practical to withdraw steroids very early after renal transplantation. However, a three- to seven-d course of steroids may decrease the risk for DGF relative to steroid withdrawal in <3 d. Antibody induction is effective in preventing early AR.
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Affiliation(s)
- Xin Zhang
- Department of Organ Transplantation, Changzheng Hospital, Shanghai, China
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