Corticosteroid withdrawal after renal transplantation in the cyclosporin era - Timing, benefits and risks

In an effort to eliminate the well-known adverse effects of long term corticosteroid therapy, a number of transplant centres have attempted to withdraw corticosteroids at various times following renal transplantation. Reported benefits of corticosteroid withdrawal in patients maintained on cyclosporin-based immunosuppressive regimens have included accelerated growth in children, improvements in hypertension, reductions in total cholesterol levels and improved glycaemic control for diabetic patients. However, results from single centres, and from meta-analyses of randomised prospective trials, suggest that corticosteroid-free immunosuppression is associated with an increased risk of acute allograft rejection when compared with treatment with corticosteroid-based regimens. In addition, some long term follow-up studies suggest that withdrawal of corticosteroids may increase the risk of chronic allograft dysfunction. In the cyclosporin era, the risks of corticosteroid withdrawal outweigh the benefits in a substantial minority of patients, A number of new immunosuppressants may prove to be more corticosteroid-sparing than cyclosporin, and promise to increase the safety of corticosteroid-free immunosuppression for renal transplant recipients.