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Pediatric Nephrology

, Volume 20, Issue 3, pp 418–426 | Cite as

Corticosteroid avoidance in pediatric renal transplantation

  • Jayakumar R. Vidhun
  • Minnie M. SarwalEmail author
Review

Abstract

Corticosteroids have played a central role in the evolution of renal transplant as the modality of choice for renal replacement in end stage kidney disease. Their use is associated with significant, dose related morbidity including osseous, cardiovascular, metabolic complications, body disfigurement and growth retardation in children. The strategies that have been employed to minimize these side effects include reduction in the daily administered dose of steroids, use of alternate day dosing regimens, steroid withdrawal post-transplantation and complete steroid avoidance. Steroid dose minimization has been associated with increased rates of acute rejection, though introduction of newer and more potent immunosuppressives has helped reduce the incidence of this complication. Steroid minimization will benefit patient morbidity due to cataracts, cardiovascular and osseous complications, but may offer little benefit towards improving linear growth. Alternate day steroid therapy may have a greater impact on growth improvement, but may be troubled by regimen non-adherence. Steroid withdrawal post-transplant, the ultimate target, is successful in a cohort of patients, but overall, has been historically associated with unacceptably high rates of clinical acute rejection, and has thus been used sparingly in adults and even less so in children. Complete corticosteroid avoidance, using newer induction and immunosuppressive agents, has been associated with an 8–23% incidence of acute rejection in pediatric renal transplant patients, significant catch-up growth post-transplant, improvements in post-transplant hypertension and hyperlipidemia, and a high safety profile at current follow-up. Newer induction protocols may allow complete steroid-free immunosuppression thus offering significant advantages in preventing the above-mentioned steroid related morbidity, which could also possibly be applicable to other areas of solid organ transplantation in all age groups.

Keywords

Corticosteroid Avoidance Pediatric Renal transplant Growth Daclizumab 

Notes

Acknowledgements

We would like to acknowledge the inspiration of Oscar Salvatierra, Jr. MD, Director of the Pediatric Kidney Transplant Program at Stanford University, for his support and leadership in the innovation of the pediatric steroid-free protocol discussed in the article. We also acknowledge the assistance of Stephanie Tsuchida for administrative assistance, and Martin Ho, PhD and the North American Renal Transplant Cooperative Study (NAPRTCS) Coordinating Center for providing national growth data on pediatric renal transplant recipients, which is also discussed in this chapter. The Stanford steroid-free study was supported by the David and Lucile Packard Foundation, Roche Pharmaceuticals (MS), the Clinical Center for Immunological Studies at Stanford University (MS), and the General Clinical Research Center, Stanford University.

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Copyright information

© IPNA 2005

Authors and Affiliations

  1. 1.Department of PediatricsStanford UniversityPalo AltoUSA

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