Steroid-free immunosuppression

Purpose of review Long-term survival in paediatric liver transplantation has focused attention on morbidity related to immunosuppression and-the need to reduce dependence on calcineurin inhibitors and corticosteroid steroids. Recent findings This review summarizes lessons learnt from paediatric and adult liver and renal transplantation in the use of steroid-free induction, withdrawal or minimization. Large randomized studies in adult liver and renal transplantation have indicated that rejection rates are similar on steroid-free protocols compared with either historical or randomized controls. There are significant differences in infection rates, new onset diabetes mellitus, hypertension and hyperlipidaemia, but 2- and 5-year patient and graft survival were similar, indicating that steroid avoidance was possible with the use of IL-2 receptor antibody protocols. The severity of and fibrosis rate in hepatitis C disease is less on steroid-free regimes. There was no clear effect on the development of other allorecognition or tolerance. Summary Steroid minimization is advantageous for paediatric practice and is safe and effective in the short term. Large-scale paediatric randomized studies are required to evaluate the long-term efficacy of these regimes and the use of IL-2 antibodies on the development of chronic rejection, infection, including posttransplant lymphoproliferative disease, and the development of tolerance.