Steroid-free immunosuppression in kidney transplant recipients: the University of Minnesota experience.

As results after transplants continue to improve, the burden associated with long-term immunosuppression and the complications associated with these agents become more significant. Recent trends in immunosuppression minimization strategies show that prednisone minimization protocols are not associated with significantly increased acute rejection or chronic graft dysfunction. With long-term data now available, we can see that the majority of such recipients (>80%) can remain prednisone free. There seems to be no compromise in terms of long-term results, and a definite improvement with regard to steroid-related and viral complications. These protocols can be used in minorities, children, and higher immunologic risk kidney transplant recipients, and in liver and pancreas recipients. The question of what is the ideal maintenance agent to couple with prednisone-free regimes remains unclear, and it may be that different agents may be better suited for different groups of recipients. Why is prednisone minimization now possible, when previous attempts were unsuccessful? Several explanations are possible. Early attempts concentrated on steroid withdrawal - removing prednisone once the patient had been on therapy for at least 3 months (18-20). Outcomes differ between studies reporting rapid prednisone withdrawal and those reporting prednisone withdrawal at a later time, but it is not clear why rapid prednisone withdrawal has succeeded and late prednisone withdrawal has failed. Other factors may include the routine use of polyclonal antibody for induction therapy and the use of newer immunosuppression agents such as MMF, TAC, and SRL. Finally, the newer trials of prednisone minimization have been performed in a different era, a time when results have improved as has our understanding of the risk factors associated with long-term graft survival. While ongoing follow-up of this group of patients will continue to be important, our experience suggests that maintenance prednisone is likely not required for the majority of kidney transplant recipients today.