Long-term results of cyclosporine monotherapy in renal transplantation

Comparison of 2 Immunosuppression Minimization Strategies in Kidney Transplantation: The ALLEGRO Trial

BACKGROUND

Evidence on the optimal maintenance of immunosuppressive regimen in kidney transplantation recipients is limited.

METHODS

The Amsterdam, LEiden, GROningen trial is a randomized, multicenter, investigator-driven, noninferiority, open-label trial in de novo kidney transplant recipients, in which 2 immunosuppression minimization strategies were compared with standard immunosuppression with basiliximab, corticosteroids, tacrolimus, and mycophenolic acid. In the minimization groups, either steroids were withdrawn from day 3, or tacrolimus exposure was reduced from 6 mo after transplantation. The primary endpoint was kidney transplant function at 24 mo.

RESULTS

A total of 295 participants were included in the intention-to-treat analysis. Noninferiority was shown for the primary endpoint; estimated glomerular filtration rate at 24 mo was 45.3 mL/min/1.73 m 2 in the early steroid withdrawal group, 49.0 mL/min/1.73 m 2 in the standard immunosuppression group, and 44.7 mL/min/1.73 m 2 in the tacrolimus minimization group. Participants in the early steroid withdrawal group were significantly more often treated for rejection ( P = 0.04). However, in this group, the number of participants with diabetes mellitus during follow-up and total cholesterol at 24 mo were significantly lower.

CONCLUSIONS

Tacrolimus minimization can be considered in kidney transplant recipients who do not have an increased immunological risk. Before withdrawing steroids the risk of rejection should be weighed against the potential metabolic advantages.

Steroid avoidance or withdrawal for kidney transplant recipients

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.

Steroid avoidance or withdrawal after renal transplantation increases the risk of acute rejection but decreases cardiovascular risk. A meta-analysis

INTRODUCTION

The morbidity related to long-term steroid therapy has led to continued interest in withdrawal of steroids from immunosuppressant regimens after renal transplantation. A number of recent trials have provided long-term information regarding the risks and benefits of steroid avoidance or withdrawal (SAW).

METHODS

A literature search was performed using Ovid Medline, Embase, the Cochrane Library, and the Transplant Library. Randomized controlled trials comparing a maintenance steroid group with complete avoidance or withdrawal of steroids were selected. All studies were assessed for methodological quality. Trials were pooled by meta-analysis to provide summary effects (relative risk [RR] or weighted mean difference) with 95% confidence intervals (CI).

RESULTS

Thirty-four studies including 5,637 patients met the inclusion criteria. SAW regimens significantly increased the risk of acute rejection (AR) over maintenance steroids (RR 1.56, CI 1.31-1.87, P<0.0001). No significant differences in corticosteroid resistant AR, patient survival, or graft survival were observed. Serum creatinine was increased and creatinine clearance was reduced with SAW. Cardiovascular risk factors including incidence of hypertension (RR 0.90, CI 0.85-0.94, P<0.0001), new onset diabetes (RR 0.64, CI 0.50-0.83, P=0.0006), and hypercholesterolemia (RR 0.76, CI 0.67-0.87, P<0.0001) were reduced significantly by SAW.

CONCLUSION

Despite an increase in the risk of AR with SAW protocols, there is only a small effect on graft function with no measurable effect on graft or patient survival. There are significant benefits in cardiovascular risk profiles after SAW. SAW protocols would seem justified with current immunosuppressive protocols in low-risk recipients.