Bae Sunjae, Chen Yusi, Sandal Shaifali, Lentine Krista L, Schnitzler Mark, Segev Dorry L, McAdams DeMarco Mara A
Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA.
Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
Nephrol Dial Transplant. 2025 Apr 1;40(4):662-670. doi: 10.1093/ndt/gfae218.
Early steroid withdrawal (ESW) is often preferred over conventional steroid maintenance (CSM) therapy for kidney transplant recipients with low immunological risks because it may minimize immunosuppression-related adverse events while achieving similar transplant outcomes. However, the risk-benefit balance of ESW could be less favorable in retransplant recipients given their unique immunological risk profile. We hypothesized that the association of ESW with transplant outcomes would differ between first-transplant and retransplant recipients.
To assess whether the impact of ESW differs between first and retransplant recipients, we studied 210 086 adult deceased-donor kidney transplant recipients using the Scientific Registry of Transplant Recipients. Recipients who discontinued maintenance steroids before discharge from transplant admission were classified with ESW; all others were classified with CSM. We quantified the association of ESW (vs CSM) with acute rejection, death-censored graft failure and death, addressing retransplant as an effect modifier, using logistic/Cox regression with inverse probability weights to control for confounders.
In our cohort, 26 248 (12%) were retransplant recipients. ESW was used in 30% of first-transplant and 20% of retransplant recipients. Among first-transplant recipients, ESW was associated with no significant difference in acute rejection {adjusted odds ratio (aOR) = 1.04 [95% confidence interval (CI) = 1.00-1.09]}, slightly higher hazard of graft failure [hazard ratio (HR) = 1.09 (95% CI = 1.05-1.12)] and slightly lower mortality [HR = 0.93 (95% CI = 0.91-0.95)] compared with CSM. Nonetheless, among retransplant recipients, ESW was associated with notably higher risk of acute rejection [OR = 1.42 (95% CI = 1.29-1.57); interaction P < .001] and graft failure [HR = 1.24 (95% CI = 1.14-1.34); interaction P = .003], and similar mortality [HR = 1.01 (95% CI = 0.94-1.08); interaction P = .04].
In retransplant recipients, the negative impacts of ESW on transplant outcomes appear to be non-negligible. A more conservatively tailored approach to ESW might be necessary for retransplant recipients.
对于免疫风险较低的肾移植受者，早期停用类固醇（ESW）通常比传统的类固醇维持（CSM）疗法更受青睐，因为它可以在实现相似移植结局的同时，将免疫抑制相关不良事件降至最低。然而，鉴于再次移植受者独特的免疫风险特征，ESW的风险效益平衡可能不那么有利。我们假设ESW与移植结局之间的关联在初次移植和再次移植受者中会有所不同。
为了评估ESW对初次移植和再次移植受者的影响是否不同，我们使用移植受者科学登记系统研究了210086例成年 deceased-donor 肾移植受者。在移植入院出院前停用维持类固醇的受者被归类为ESW；所有其他受者被归类为CSM。我们使用逻辑/ Cox回归和逆概率权重来控制混杂因素，将再次移植作为效应修饰因子，量化ESW（与CSM相比）与急性排斥反应、死亡删失的移植失败和死亡之间的关联。
在我们的队列中，26248例（12%）为再次移植受者。30%的初次移植受者和20%的再次移植受者使用了ESW。在初次移植受者中，与CSM相比，ESW与急性排斥反应无显著差异（调整优势比[aOR]=1.04[95%置信区间（CI）=1.00-1.09]），移植失败风险略高[风险比（HR）=1.09（95%CI=1.05-1.12）]，死亡率略低[HR=0.93（95%CI=0.91-0.95）]。尽管如此，在再次移植受者中，ESW与急性排斥反应风险显著更高[OR=1.42（95%CI=1.29-1.57）；交互作用P<0.001]和移植失败风险更高[HR=1.24（95%CI=1.14-1.34）；交互作用P=0.003]相关，死亡率相似[HR=1.01（95%CI=0.94-1.08）；交互作用P=0.04]。
在再次移植受者中，ESW对移植结局的负面影响似乎不可忽视。对于再次移植受者，可能需要一种更保守的ESW定制方法。
