Early Steroid Withdrawal in Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function
Authors: Sunjae Bae, Jacqueline M. Garonzik Wang, Allan B. Massie, Kyle R. Jackson, Mara A. McAdams-DeMarco, Daniel C. Brennan, Krista L. Lentine, Josef Coresh, Dorry L. Segev
Journal: Journal of the American Society of Nephrology (2019)

Significance Statement Early steroid withdrawal (ESW) is a maintenance immunosuppression strategy to avoid the sequelae of long-term steroid use in kidney transplant (KT) recipients. Recipients with delayed graft function (DGF) may have a suboptimal allograft milieu, which may alter the risk/benefit equation of ESW. In this nationwide study, the authors found use of ESW in recipients with DGF varied at United States transplant centers. The authors also identified differences in outcomes after ESW in patients with and without DGF. Among recipients with immediate graft function, ESW was associated with possible harms such as increased rejection and benefits such as decreased mortality. However, among recipients with DGF, ESW was associated only with possible harms, including increased acute rejection and graft failure. Recipients with DGF also saw no change mortality with ESW. Our findings suggest ESW is harmful in KT recipients with DGF. Background Early steroid withdrawal (ESW) is associated with acceptable outcomes in kidney transplant (KT) recipients. Recipients with delayed graft function (DGF), however, often have a suboptimal allograft milieu, which may alter the risk/benefit equation for ESW. This may contribute to varying practices across transplant centers. Methods Using the Scientific Registry of Transplant Recipients, we studied 110,019 adult deceased-donor KT recipients between 2005 and 2017. We characterized the association of DGF with the use of ESW versus continued steroid maintenance across KT centers, and quantified the association of ESW with acute rejection, graft failure, and mortality using multivariable logistic and Cox regression with DGF-ESW interaction terms. Results Overall 29.2% of KT recipients underwent ESW. Recipients with DGF had lower odds of ESW (aOR= 0.60 0.67 0.75 ). The strength of this association varied across 261 KT centers, with center-specific aOR of &lt;0.5 at 31 (11.9%) and &gt;1.0 at 22 (8.4%) centers. ESW was associated with benefits and harms among recipients with immediate graft function (IGF), but only with harms among recipients with DGF. ESW was associated with increased acute rejection (aOR= 1.09 1.16 1.23 ), slightly increased graft failure (aHR= 1.01 1.06 1.12 ), but decreased mortality (aHR= 0.86 0.89 0.93 ) among recipients with IGF. Among recipients with DGF, ESW was associated with a similar increase in rejection (aOR=1.12; 95% CI, 1.02 to 1.23), a more pronounced increase in graft failure (aHR=1.16; 95% CI, 1.08 to 1.26), and no improvement in mortality (aHR=1.00; 95% CI, 0.94 to 1.07). DGF-ESW interaction was statistically significant for graft failure ( P =0.04) and mortality ( P =0.003), but not for rejection ( P =0.6). Conclusions KT centers in the United States use ESW inconsistently in recipients with DGF. Our findings suggest ESW may lead to worse KT outcomes in recipients with DGF.