Graft and patient survival in kidney transplant recipients selected for de novo steroid-free maintenance immunosuppression

Abstract

Steroid-free regimen is increasingly employed in kidney transplant recipients across transplant centers. However, concern remains because of the unknown impact of such an approach on long-term graft and patient survival. We studied the outcomes of steroid-free immunosuppression in a population-based U.S. cohort of kidney transplant recipients. All adult solitary kidney transplant recipients engrafted between January 1, 2000 and December 31, 2006 were stratified according to whether they were selected for a steroid-free or steroid-containing regimen at discharge. Multivariate Cox regression models were used to estimate graft and patient survival. The impact of the practice pattern on steroid use at individual transplant centers was analyzed. Among 95 755 kidney transplant recipients, 17.2% were steroid-free at discharge (n = 16 491). Selection for a steroid-free regimen was associated with reduced risks for graft failure and death at 1 year (HR 0.78, 95% CI 0.72-0.85, and HR 0.73, 95% CI 0.65-0.82, respectively, p < 0.0001) and 4 years (HR 0.83, 95% CI 0.78-0.87, and HR 0.76, 95% CI 0.71-0.83, respectively, p < 0.0001). This association was mostly observed at individual centers where less than 65% of recipients were discharged on the steroid-containing regimen. De novo steroid-free immunosuppression as currently practiced in the United States appears to carry no increased risk of adverse clinical outcomes in the intermediate term.

Figure 1

Trends in steroid-free immunosuppression at discharge for kidney transplant recipients in U.S. transplant centers, 2000-2006.

Figure 2

Hazard ratio for death censored graft failure a), and patient death b), at one and four years according to the percentage of steroid use at discharge among individual transplant centers.

Figure 2

Hazard ratio for death censored graft failure a), and patient death b), at one and four years according to the percentage of steroid use at discharge among individual transplant centers.

Figure 3

Induction usage among kidney transplant recipients discharged without steroid a), and with steroid b).

Figure 4

Hazard ratio for death censored graft failure a), and patient death b), at one and four years for kidney transplant recipients receiving no steroid at discharge according to various induction agents.

Figure 4

Hazard ratio for death censored graft failure a), and patient death b), at one and four years for kidney transplant recipients receiving no steroid at discharge according to various induction agents.

Figure 5

Hazard ratio for death censored graft failure a), and patient death b), at one and four years for kidney transplant recipients receiving no steroid at discharge according to the maintenance immunosuppressive regimen at discharge. All regimens are significantly different from the reference group Tac/MMF at p value <0.0001 except where indicated otherwise.

Figure 5

Hazard ratio for death censored graft failure a), and patient death b), at one and four years for kidney transplant recipients receiving no steroid at discharge according to the maintenance immunosuppressive regimen at discharge. All regimens are significantly different from the reference group Tac/MMF at p value <0.0001 except where indicated otherwise.