Effect of long-term steroid withdrawal in renal transplant recipients: a retrospective cohort study

Impact of kidney transplantation on functional status

BACKGROUND AND AIMS

Functional capacity (FC) is known to affect morbidity and mortality in kidney transplantation. Despite this important role, little is known about the variables influencing post-transplant FC. Our study aims at identifying these crucial associations.

METHOD

Our study included 16,684 renal transplant recipients (RTR). Patients had transplant between 1 September 2018 and 1 September 2019. Mild functional impairment was defined as those with a KPSS score > or = 80; moderate functional impairment was defined as those with a KPSS score between 50 and 70 and severe functional impairment was defined as those with a KPSS score < or =40. The outcome measured was FC at follow-up one-year post-transplant. Abnormal FC at follow-up was defined as those with KPSS score less than 80%. Normal FC at follow-up was defined as those with KPSS score equal or above 80%. Multivariate logistic regression was used to assess with the relationship between patient characteristics and abnormal functional status post-transplant.

RESULTS

Three groups were identified; those with none-to-mild functional impairment at time of transplant (Group A; n = 8388), those who had moderate impairment at time of transplant (Group B; n = 7694) and those who had severe impairment at time of transplant (Group C; n = 602). Abnormal FC at one-year post transplant was present in 7.69%, 28.89%, 49.49% of patients in group A, B and C, respectively. Glucocorticoid withdrawal was associated with lower risk of developing abnormal FC post-transplant (OR = 0.75, p value = .02, 95% confidence intervals: 0.64 to 0.97), while recipient diabetes was associated with higher risk of abnormal FC (OR = 1.44, p value <.01, 95% confidence intervals: 1.20 to 1.74) in adjusted model.

CONCLUSION

Kidney transplantation is associated with substantial improvement in all stages of FC in KTRs. Glucocorticoid withdrawal and diabetes mellitus are potentially modifiable factors of FC and merit further considerations during pre-transplant workup and post-transplant immunosuppressive therapeutic planning.Key messagesKidney transplantation is associated with substantial improvement in all stages of FC in KTRs.Glucocorticoid withdrawal and diabetes mellitus are potentially modifiable factors of FC and merit further considerations during pre-transplant workup and post-transplant immunosuppressive therapeutic planning.

Donor-specific antibodies development in renal living-donor receptors: Effect of a single cohort

Minimization in immunosuppression could contribute to the appearance the donor-specific HLA antibodies (DSA) and graft failure. The objective was to compare the incidence of DSA in renal transplantation (RT) in recipients with immunosuppression with and without steroids. A prospective cohort from March 1st, 2013 to March 1st, 2014 and follow-up (1 year), ended in March 2015, was performed in living donor renal transplant (LDRT) recipients with immunosuppression and early steroid withdrawal (ESW) and compared with a control cohort (CC) of patients with steroid-sustained immunosuppression. All patients were negative cross-matched and for DSA pre-transplant. The regression model was used to associate the development of DSA antibodies and acute rejection (AR) in subjects with immunosuppressive regimens with and without steroids. Seventy-seven patients were included (30 ESW and 47 CC). The positivity of DSA class I (13% vs 2%; P < 0.05) and class II (17% vs 4%, P = 0.06) antibodies were higher in ESW versus CC. The ESW tended to predict DSA class II (RR 5.7; CI (0.93–34.5, P = 0.06). T-cell mediated rejection presented in 80% of patients with DSA class I (P = 0.07), and 86% with DSA II (P = 0.03), and was associated with DSA class II, (RR 7.23; CI (1.2–44), P = 0.03). ESW could favor the positivity of DSA. A most strictly monitoring the DSA is necessary for the early stages of the transplant to clarify the relationship between T-cell mediated rejection and DSA.

Conversion from Twice-Daily to Once-Daily Tacrolimus Improves Graft Function but has no Influence on Proteinuria in Renal Transplant Recipients

Introduction. Tacrolimus extended-release formulation enables once-daily use. Although an increasing number of patients have been converted from twice-daily (Tac- BID) to once-daily (Tac-QD) formulation, the available information regarding the initiation and follow-up of Tac- QD is sparse. In the present study we investigated influence of switch from Tac-BID or cyclosporine to Tac-QD on renal allograf function, proteinuria and protein-creatinine (P/C) ratio. Methods. Between October 2012 and October 2014, the switch from Tac-BID or cyclosporine to tacrolimus extended-release formulation was done in 129(38% female, mean age 49 years) renal transplant recipients at different time after transplantation. The analysis focused on markers of graft function (GFR, serum creatinine, proteinuria, P/C ratio), liver function (AST, ALT, γGT, alkaline phosphatase) and blood glucose. Clinical data were obtained at baseline (before conversion), 1 month (V1), 6 months (V6) and 12 months (V12) after conversion. Results. Both serum creatinine and GFR showed a statistically significant improvement. With GFR, signifycant improvement was observed as early as V1 and it continued to increase throughout the study period up to V12 (all between-visit changes were statistically significant). With serum creatinine, mean levels were numerically decreasing throughout the follow-up period, but a significant improvement occurred at V6 and remained significant at V12 (both vs. V0 values). Proteinuria and P/C ratio did not show any significant change through the observation period. In the majority of patients, the baseline values of AST, ALT, GGT, AlP and glucose were within normal limits and did not change significantly through the observation period. Analysis of tacrolimus C0 showed a significant decrease throughout the follow-up period, at practically all visit. This finding was paralleled by a significant tacrolimus dose decrease from baseline to V6 and V12, as well as by a significant decrease of tacrolimus dose/body weight. Conclusions. Conversion from cyclosporine or Tac-BID to extended-release Tac-QD improves graft function in renal transplant recipients, without influence on proteinuria or P/C ratio.

Impact of Maintenance Steroids versus Rapid Steroid Withdrawal in African-American Kidney Transplant Recipients: Comparison of Two Urban Centers

Background

Rapid steroid withdrawal (RSW) is used increasingly in kidney transplantation but long-term outcomes in African-American (AA) recipients are not well known. We compared 1 and 5 year transplant outcomes in a large cohort of AA patients who were maintained on continued steroid therapy (CST) to those who underwent RSW.

Methods

Post-transplant courses of A as receiving kidney allografts from 2003–2011 at two urban transplant centers in Chicago were followed. Prior to outcome analysis, we used Inverse Probability of Treatment Weights (IPTW) to match the two groups on a set of baseline risk factors. Graft and patient survival, GFR at 1 and 5 years, incidence and type of rejection, incidence of post-transplant diabetes mellitus (PTDM), delayed graft function, CMV and BK viremia were compared.

Results

There were 150 AA recipients in the CST analytic group and 157 in the RSW analytic group. Graft and patient survival was similar between the two groups. Rates of CMV viremia were higher in the RSW compared to the CST analytic group at 1 year. Biopsy-proven acute rejection and PTDM were similar between the RSW and CST groups.

Conclusions

In AA recipients, RSW has similar long-term outcomes to CST.