Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.
HLA-Diagnostics and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland.
Clin Transplant. 2018 Mar;32(3):e13181. doi: 10.1111/ctr.13181. Epub 2018 Feb 6.
Steroid withdrawal following renal transplantation is challenging and widely debated. This retrospective study aimed at investigating the frequency and determinants of successful steroid withdrawal guided by surveillance biopsies. We analyzed 156 pretransplant DSA-negative renal transplants receiving basiliximab induction and maintenance immunosuppression with tacrolimus-mycophenolate-steroids. The absence of rejection in surveillance biopsies at 3 or 6 months post-transplant initiated steroid withdrawal, which was monitored by subsequent indication and/or surveillance biopsies. The primary outcome was the frequency of successful (i.e., rejection-free) steroid withdrawal at 1 year post-transplant. In the whole study population, successful steroid withdrawal was achieved in 73 of 156 patients (47%). Steroid withdrawal was initiated in 98 of 156 patients (63%) and successful in 73 of 98 patients (74%). Subsequent clinical rejection occurred in only one of 98 patients (1%), whereas 24 of 98 patients (24%) experienced subclinical rejection. Steroid withdrawal was not initiated in 58 of 156 patients (37%) mainly due to current or prior severe (Banff TCMR ≥IA) subclinical rejection. Prediction of successful steroid withdrawal by pretransplant or early post-transplant parameters was poor. In conclusion, (sub)clinical rejection-free steroid withdrawal can be expected in about half of pretransplant DSA-negative patients. As successful steroid withdrawal cannot be well predicted by pre- and early post-transplant parameters, guidance by surveillance biopsies is an attractive strategy.
肾移植后停用类固醇具有挑战性，且广泛存在争议。本回顾性研究旨在通过监测活检来调查指导下成功停用类固醇的频率和决定因素。我们分析了 156 例接受巴利昔单抗诱导和他克莫司-霉酚酸酯-类固醇维持免疫抑制的预移植 DSA 阴性肾移植患者。移植后 3 或 6 个月监测活检中无排斥反应时开始停用类固醇，随后通过指示和/或监测活检进行监测。主要结局是移植后 1 年成功（即无排斥反应）停用类固醇的频率。在整个研究人群中，156 例患者中有 73 例（47%）成功停用类固醇。在 156 例患者中，有 98 例（63%）开始停用类固醇，其中 73 例（74%）成功。仅在 98 例患者中有 1 例（1%）发生后续临床排斥反应，而在 98 例患者中有 24 例（24%）发生亚临床排斥反应。有 58 例患者（37%）未开始停用类固醇，主要是由于当前或之前存在严重（Banff TCMR ≥IA）亚临床排斥反应。通过移植前或移植后早期参数预测成功停用类固醇的效果不佳。总之，约一半的预移植 DSA 阴性患者可实现无（亚）临床排斥反应的类固醇停药。由于成功停用类固醇不能通过移植前和移植早期参数很好地预测，因此监测活检指导是一种有吸引力的策略。
