What is the issue?
Each year more than 28,000 kidney transplants are performed globally. Kidney transplantation is the treatment of choice for eligible people who have lost kidney function. Most kidney transplant recipients receive corticosteroids as part of their immunosuppression treatment. Steroids are effective in preventing acute rejection, which is a major problem in the early period after kidney transplantation. However, steroids can also lead to serious side effects when taken long-term. This review looked at two strategies to reduce steroid administration after kidney transplantation: either discontinuing steroids soon after transplantation (within 14 days) or stopping steroid treatment later.
What did we do?
We searched the literature up to February 2016 and identified 48 studies (7803 patients) that were evaluated in this review. Only three studies included children. This is an update of a review that was last published in 2009.
What did we find?
Our review looked at data relating to 7803 kidney transplant recipients. We assessed the risk of bias in all studies and found that most were unblinded, about half did not report funding sources or how they randomised and allocated study participants.
We found that the risk of acute rejection significantly increased with both steroid-reducing treatments among adults who received kidney transplants. There was no little or no difference in the numbers of deaths or loss of transplanted kidneys for both steroid-reducing strategies within five years after kidney transplantation. Side effects, such as infection, cancer or diabetes after transplantation did not differ between groups of patients whose steroids were discontinued compared with those who continued to take steroids. The effect of steroid withdrawal in children is unclear.
There was no evidence to suggest a difference in patient mortality or graft loss up to five year after transplantation, but longer-term consequences of steroid avoidance and withdrawal still remain unclear.
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-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.
To evaluate the benefits and harms of steroid withdrawal or avoidance for kidney transplant recipients.
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.
All randomised and quasi-randomised controlled trials (RCTs) in which steroids were avoided or withdrawn at any time point after kidney transplantation were included.
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.
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.