Recurrence of IgA nephropathy after kidney transplantation in steroid continuation versus early steroid-withdrawal regimens: a retrospective analysis of the UNOS/OPTN database

Abstract

In the past 20 years, there has been an increase in use of steroid-withdrawal regimens in kidney transplantation. However, steroid withdrawal may be associated with an increased risk of recurrent IgA nephropathy (IgAN). Using United Network of (Organ Sharing/Organ Procurement and Transplantation Network) UNOS/OPTN data, we analyzed adult patients with end-stage renal disease (ESRD) due to IgAN who received their first kidney transplant between 2000 and 2014. For the primary outcome, we used a competing risk analysis to compare the cumulative incidence of graft loss due to IgAN recurrence between early steroid-withdrawal (ESW) and steroid continuation groups. The secondary outcomes were patient survival and death-censored graft survival (DCGS). A total of 9690 recipients were included (2831 in ESW group and 6859 in steroid continuation group). In total, 1238 recipients experienced graft loss, of which 191 (15.43%) were due to IgAN recurrence. In multivariable analysis, steroid use was associated with a decreased risk of recurrence (subdistribution hazard ratio 0.666, 95% CI 0.482-0.921; P = 0.014). Patient survival and DCGS were not different between the two groups. In the USA, ESW in transplant for ESRD due to IgAN is associated with a higher risk of graft loss due to disease recurrence. Future prospective studies are warranted to further address which patients with IgAN would benefit from steroid continuation.

Keywords: IgA nephropathy; immunosuppression; steroids; transplant outcomes.

Figure 1

Figure 1a. Steroid-use upon discharge categorized by transplant eras; 13.74%, 35.26% and 35.69% of the recipients were steroid-free upon discharge in 2000–2004, 2005–2009 and 2010–2014 eras, respectively. Figure 1b. Steroid use at a year follow-up categorized by transplant eras excluding those who had failed allograft at a year; 15.44%, 34.86% and 32.37% of the recipients were steroid-free upon discharge in 2000–2004, 2005–2009 and 2010–2014 eras, respectively with 6.50%, 7.97% and 4.51% of recipients that had missing value, respectively.

Figure 1

Figure 1a. Steroid-use upon discharge categorized by transplant eras; 13.74%, 35.26% and 35.69% of the recipients were steroid-free upon discharge in 2000–2004, 2005–2009 and 2010–2014 eras, respectively. Figure 1b. Steroid use at a year follow-up categorized by transplant eras excluding those who had failed allograft at a year; 15.44%, 34.86% and 32.37% of the recipients were steroid-free upon discharge in 2000–2004, 2005–2009 and 2010–2014 eras, respectively with 6.50%, 7.97% and 4.51% of recipients that had missing value, respectively.

Figure 2

Ten-year unadjusted cumulative incidence of graft loss due to IgA recurrence stratified by steroid use upon discharge

Figure 3

Figure 3a. Unadjusted Kaplan-Meier patient survival curves in ESW groups compared to steroid continuation groups stratified by donor type. Figure 3b. Unadjusted Kaplan-Meier death-censored graft survival curves in ESW groups compared to steroid continuation groups stratified by donor type.

Figure 3

Figure 3a. Unadjusted Kaplan-Meier patient survival curves in ESW groups compared to steroid continuation groups stratified by donor type. Figure 3b. Unadjusted Kaplan-Meier death-censored graft survival curves in ESW groups compared to steroid continuation groups stratified by donor type.