Abstract
Over the last decade, steroid minimization became one of the major goals in pediatric renal transplantation. Different protocols have been used by individual centers and multicenter study groups, including early and late steroid withdrawal or even complete avoidance. The timing of steroid withdrawal determines if antibodies are used, as avoidance and early withdrawal require antibody induction, while late withdrawal typically does not. A monoclonal antibody was used in most protocols during an early steroid withdrawal together with tacrolimus and mycophenolate mofetil in low immunological risk patients. Polyclonal induction was reported as effective in high-risk patients. Cyclosporine A and mycophenolate mofetil were used in late steroid withdrawal with no induction. All described protocols were effective in terms of preventing acute rejection and preserving renal graft function. There was no superiority of any specific protocol in terms of clinical benefits of steroid withdrawal. Pre-puberty determined growth benefit while other clinical advantages, including better control of glycemia, lipids, and blood pressure, were age independent. It is not clear whether the steroid withdrawal increases the risk of recurrence of primary glomerular diseases post-transplant, however it cannot be excluded. There is no evidence to date for a higher risk of anti-HLA production in steroid-free children after renal transplantation.
Key summary points
- Current strategies to minimize the steroid-related adverse effects in pediatric renal graft recipients include steroid withdrawal, early or late after transplantation, or complete steroid avoidance
- Early steroid withdrawal or avoidance is generally used following the induction therapy with mono- or polyclonal antibodies, while in late steroid withdrawal induction therapy was generally not used
- Elimination of steroids (early or late) does not increase the risk of acute rejection and does not deteriorate long-term renal graft function
- Early steroid withdrawal is possible in patients at high immunological risk using a combination of polyclonal antibody induction, tacrolimus, and mycophenolate mofetil
- All protocols of steroid minimization showed relevant clinical benefits, however the growth-related benefit was limited to pre-pubertal patients in all but one of the studies
- Adverse events of steroid withdrawal occurred in a higher incidence of post-transplant bone marrow suppression
Key research points
- There is no clear evidence of the impact of steroid withdrawal on the risk of recurrence of primary glomerulonephritis after renal transplantation in children, therefore further evaluation of this important issue should be performed in prospective trials
- There is limited pediatric data on the risk of anti-HLA/donor-specific antibody production in steroid-free patients after renal transplantation. It is not clear whether the selection of the type of induction antibody (lymphocyte depleting versus short, two-dose administration of anti-IL2R inhibitor) is important in this term. The production of anti-HLA antibodies should then be monitored on a regular basis and analyzed in prospective trials.
References
Nehus E, Goebel J, Abraham E (2012) Outcomes of steroid-avoidance protocols in pediatric kidney transplant recipients. Am J Transplant. doi:10.1111/j.1600-6143.2012.04278.x
Höcker B, Weber L, Feneberg R, Drube J, John U, Fehrenbach H, Pohl M, Zimmering M, Frϋnd S, Klaus G (2010) Wühl, Tönshoff B (2010) Improved growth and cardiovascular risk after late steroid withdrawal: 2-year results of a prospective, randomized trial in paediatric renal transplantation. Nephrol Dial Transplant 25:617–624
Sarwal MM, Vidhun JR, Alexander SR, Satterwhite T, Millan M, Salvatierra O Jr (2003) Continued superior outcomes with modification and lengthened follow-up of a steroid-avoidance pilot with extended daclizumab induction in pediatric renal transplantation. Transplantation 76(9):1331–1339
Shapiro R, Ellis D, Tan HP, Moritz ML, Basu A, Vats AN, Khan AS, Gray EA, Zeevi A, McFeaters C, James G, Grosso MJ, Marcos A, Starzl TE (2006) Antilimphoid antibody preconditioning and tacrolimus monotherapy for pediatric kidney transplantation. J Pediatr 148(6):813–818
Chavers BM, Chang C, Gillingham KJ, Matas A (2009) Pediatric kidney transplantation using a novel protocol of rapid (6-day) discontinuation of prednisolone: 2-year results. Transplantation 88(2):237–241
Grenda R, Watson A, Trompeter R, Tönshoff B, Jaray J, Fitzpatrick M, Murer L, Vondrak K, Maxwell H, van Damme-Lombaerts R, Loirat C, Mor E, Cochat P, Milford DV, Brown M, Webb NJ (2010) A randomized trial to assess the impact of early steroid withdrawal on growth in pediatric renal transplantation: the TWIST Study. Am J Transplant 10:828–836
Delucchi A, Valenzuela M, Lillo A, Lillo AM, Guerro JL, Cano F, Azocar M, Zambrano P, Salas P, Pinto V, Ferrario M, Rodriguez J, Cavada G (2011) Early steroid withdrawal in pediatric renal transplant: five years of follow-up. Pediatr Nephrol 26(12):2235–2244
Grenda R, Webb NJA (2011) Steroid minimization in pediatric renal transplantation: early withdrawal or avoidance? Pediatr Transplant 14:961–967
Pape L, Offner G, Kreuzer M, Froede K, Drube J, Kanzelmeyer N, Ehrich JH (2010) Ahlenstiel T (2010) De novo therapy with everolimus, low-dose cyclosporine A, basiliximab and steroid elimination in pediatric kidney transplantation. Am J Transplant 10(10):2349–2354
Delucchi A, Valenzuela M, Ferrario M, Lillo AM, Guerrero JL, Rodriguez E, Cano F, Cavada G, Godoy J, Rodriguez J, Gonzalez CG, Buckel E, Contreras L (2007) Early steroid withdrawal in pediatric renal transplant on newer immunosuppressive drugs. Pediatr Transplant 11:743–748
Benfield MR, Bartosh S, Ikle D, Warshaw B, Bridges N, Morrison Y, Harmon W (2010) A randomized double-blind, placebo controlled trial of steroid withdrawal after pediatric renal transplantation. Am J Transplant 10:81–88
Li L, Chaudhury A, Chen A, Zhao X, Bezchinsky M, Concepcion W, Salvatierra O Jr, Sarwal MM (2010) Efficacy and safety of thymoglobulin induction as an alternative approach for steroid-free maintenance immunosuppression in pediatric renal transplantation. Transplantation 90:1516–1520
Birkeland SA, Larsen KE, Rohr N (1998) Pediatric renal transplantation without steroids. Pediatr Nephrol 12:87–92
Oberholzer J, John E, Lumpaopong A, Testa G, Sankary HN, Briars L, Kraft KA, Knight PS, Verghese P, Benedetti E (2005) Early discontinuation of steroids is safe and effective in pediatric kidney transplant recipients. Pediatr Transplant 4:456–463
Iorember FM, Patel HP, Ohana A, Hayes JR, Mahan JD, Baker PB, Rajab A (2010) Steroid avoidance using sirolimus and cycloporine in pediatric renal transplantation: one year analysis. Pediatr Transplant 14:93–99
Motoyama O, Hasegawa A, Ohara T, Satoh M, Shishido S, Honda M, Tsuzuki K, Kinukawa T, Hattori M, Ito K, Ogawa O, Yanagihara T, Saito K, Takahashi K, Ohshima S (2005) A prospective trial of steroid withdrawal after renal transplantation treated with cyclosporine and mizoribine in children: results obtained between 1990 and 2003. Pediatr Transplant 9(2):232–238
Tan HP, Donaldson J, Ellis D, Moritz ML, Basu A, Morgan C, Vats AN, Erkan E, Shapiro R (2008) Pediatric living donor kidney transplantation under alemtuzumab pretreatment and tacrolimus monotherapy: 4-year experience. Transplantation 86(12):1725–1731
Höcker B, John U, Plank C, Wühl E, Webwer LT, Misselwitz J, Rashwer W, Mehls O, Tönshoff B (2004) Successful withdrawal of steroids in pediatric renal transplant recipients receiving cyclosporine A and mycophenolate mofetil treatment: results after four years. Transplantation 78:228–234
Laube G, Falger J, Kemper M, Zingg-Schenk A, Neuhaus TJ (2007) Selective late steroid withdrawal after renal transplantation. Pediatr Nephrol 22:1947–1952
Pape L, Lehner F, Blume C, Ahlenstiel T (2011) Pediatric kidney transplantation by de novo therapy with everolimus, low-dose cyclosporine A and steroid elimination: 3-year data. Transplantation 92(6):658–662
Montini G, Murer L, Ghio L, Pietrobon B, Ginevri F, Ferraresso M, Cardillo M, Scalamogna M, Perfumo F, Edefonti A, Zanon GF, Zacchello G (2005) One-year results of basiliximab induction and tacrolimus associated with sequential steroid and MMF treatment in pediatric kidney transplant recipients. Transpl Int 18(1):36–42
McDonald RA, Smith JM, Ho M, Lindblad R, Ikle D, Grimm P, Wyatt R, Arar M, Liereman D, Bridges N, Harmon W, for CCTPT Group (2008) Incidence of PTLD in pediatric renal transplant recipients receiving basiliximab, calcineurin inhibitor, sirolimus and steroids. Am J Transplant 8:984–989
Li L, Chang A, Naesens M, Kambham N, Waskerwitz J, Martin J, Wong C, Alexander S, Grimm P, Concepcion W, Salvatierra O, Sarwal MM (2009) Steroid-free immunosuppression since 1999: 129 pediatric renal transplants with sustained graft and patient benefits. Am J Transplant 9:1362–1372
Silverstein D, Aviles D, LeBlanc PM, Jung FF, Vehaskari VM (2005) Results of one-year follow-up of steroid-free immunosuppression in pediatric renal transplant patients. Pediatr Transplant 9(5):589–597
Bhakta N, Marik J, Malekzadeh M, Gjertson D, Ettenger R (2008) Can pediatric steroid-free renal transplantation improve growth and metabolic complications? Ped Transplant 12:854–861
Klare B, Montoya C, Fischer DC, Stangl MJ, Haffner D (2012) Normal adult height after steroid-withdrawal within 6 months of pediatric kidney transplantation: a 20-year single-center experience. Transplant Int 25:276–282
Grenda R, Karczmarewicz E, Rubik J, Matusik H, Pludowski P, Kiliszek M, Piskorski J (2011) Bone mineral density in children after renal transplantation in steroid-free and steroid-treated patients—a prospective study. Pediatr Transplant 15:205–213
Smith JM, Rudser K, Gillen D, Kestenbaum B, Seliger S, Weiss N, McDonald RA, Davis CL, Stehmen-Breen C (2006) Risk of lymphoma after renal transplantation varies with time: analysis of the United States Renal Data System. Transplantation 81:175–180
Opelz G, Naujokat C, Daniel V, Terness P, Döhler B (2006) Disassociation between risk of graft loss and risk of non-Hodgkin lymphoma with induction agents in renal transplant recipients. Transplantation 61:1227–1233
Smith JM, Dhanidharka VR, Talley L, Martz K, McDonald RA (2007) BK virus nephropathy in pediatric renal transplant recipients: an analysis of North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry. Clin J Am Soc Nephrol 2(5):1037–1042
Delgado JC, Fuller A, Ozawa M, Smith L, Terasaki PI, Shihab FS, Eckels DD (2009) No occurrence of de novo HLA antibodies in patients with early corticosteroid withdrawal in a 5-year prospective randomized study. Transplantation 87:546–548
Sutherland S, Li L, Concepcion W, Salvatierra O, Sarwal MM (2009) Steroid-free immunosuppression in pediatric renal transplantation: rationale outcomes following conversion to steroid based therapy. Transplantation 87:1744–1748
Chavers BM, Rheault MN, Gilligham KJ, Matas AJ (2012) Graft loss due to recurrent disease in pediatric kidney transplant recipients on a rapid prednisolone discontinuation protocol. Pediatr Transplant 16:704–710
Conflict of interest
None declared.
Author information
Authors and Affiliations
Corresponding author
Additional information
Answers
1 Answer 3: Is increasing as there is growing evidence of efficacy and safety
2 Answer 4: Is safe and effective in terms of growth benefit in pre-pubertal children
3 Answer 1: Extended monoclonal induction with daclizumab up to 6 months post-transplant
4 Answer 4: All types of mono- and polyclonal antibodies
5 Answer 2: Improved growth in both pubertal and pre-pubertal children, combined with better blood pressure, glucose and lipid control
Multiple-choice questions (answers are provided following the reference list)
Multiple-choice questions (answers are provided following the reference list)
-
1:
In the last decade, the use of steroid minimization protocols in pediatric renal transplantation:
-
1.
Is less common due to chronic rejection
-
2.
Concerns less than 5 % of patients
-
3.
Is increasing, as there is growing evidence of efficacy and safety
-
4.
Was used only in pre-pubertal children
-
1.
-
2:
Late steroid withdrawal (beyond 1 year post-transplantation):
-
1.
Is not used any more
-
2.
Is possible only in patients receiving tacrolimus and sirolimus
-
3.
Does not provide growth benefits, which is lost during the first year of follow-up
-
4.
Is safe and effective in terms of growth benefits in pre-pubertal children
-
1.
-
3:
Complete avoidance of steroids in pediatric renal transplantation was achieved with:
-
1.
Extended monoclonal induction with daclizumab up to 6 months, post-transplant
-
2.
7-day polyclonal induction, combined with tacrolimus-everolimus maintenance immunosuppression
-
3.
Preconditioning with IVIG and rituximab
-
4.
Immunoadsorption
-
1.
-
4:
Induction protocols used for early steroid withdrawal (<7 days post-transplant), used:
-
1.
Only anti-IL2R inhibitors: basiliximab or daclizumab
-
2.
Only polyclonal antibodies
-
3.
Only alemtuzumab
-
4.
All types of mono- and polyclonal antibodies
-
1.
-
5:
Clinical benefits of steroid-minimization in children include:
-
1.
Improved growth and blood pressure control in obese adolescents
-
2.
Improved growth in both pubertal and pre-pubertal children, combined with better blood pressure, glucose and lipid control
-
3.
Improved glucose and not lipid metabolism
-
4.
Improved bone marrow function
-
1.
Rights and permissions
About this article
Cite this article
Grenda, R. Steroid withdrawal in renal transplantation. Pediatr Nephrol 28, 2107–2112 (2013). https://doi.org/10.1007/s00467-012-2391-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00467-012-2391-6