Withdrawal of steroids from triple-drug therapy in kidney transplant patients

Ivo Matl1,, Jirí Lácha1, Alena Lodererová2, Marcela Símová1, Vladimír Teplan1, Vera Lánská3 and Stefan Vítko4

1 Department of Nephrology, 2 Department of Pathology, 3 Department of Statistics and 4 Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic



   Abstract
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
Background. In renal transplant patients with stable graft function, triple-drug immunosuppression may not be necessary, while withdrawal of steroids may eliminate side effects. The primary aim of this study was to assess the risk of rejection after steroid withdrawal.

Methods. A total of 88 patients with stable graft function and serum creatinine <160 µmol/l, treated with cyclosporin A, azathioprine and prednisone were randomized into group A (n=46) with a gradual prednisone reduction to zero in the course of 6 months, and group B (n=42) on triple-drug therapy without change. At the time of randomization, fine-needle aspiration biopsy (FNAB) was carried out in all of the patients. After stopping steroids, the patients were followed up for a period of 12 months.

Results. Four patients failed to complete steroid withdrawal, three due to rejection, and one due to leukopenia. The proportion of rejection in three patients in group A (6.6%) was not significantly different from rejection in two patients in group B (4.8%). The mean value of serum creatinine was not significantly different in both groups in the course of follow-up. A finding of some degree of immunological activity in FNAB was made in four patients in each group, but none of these patients developed rejection. Compared with group B, significant decreases in serum cholesterol and blood leukocytes were observed in group A. Prednisone withdrawal did not have any influence on hypertension and serum triglycerides.

Conclusions. Gradual withdrawal of steroids is not associated with a higher risk for rejection and has a beneficial effect on serum total cholesterol levels. FNAB was not a useful tool for predicting rejection.

Keywords: fine-needle aspiration biopsy; immunosuppressive treatment; kidney transplantation; rejection; steroid withdrawal; triple-drug therapy



   Introduction
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
Triple-drug therapy is the most widely used regimen in kidney transplantation [1], but no benefit of its long-term use has been demonstrated, and it may be unnecessary in most patients. Because of their side effects, steroids are the first candidate to be removed from the immunosuppressive regimen. Steroid-free therapy would be beneficial for particular groups of patients such as children [2], elderly [3], diabetics [4], patients with osteoporosis [5] and hyperlipidaemia [6]. The main risk associated with steroid withdrawal is rejection [7]. One of the important factors is the timing of steroid withdrawal [7].

The aim of this project was to assess the risk for rejection in a controlled study where steroids were withdrawn 1 year after transplantation, employing fine-needle aspiration biopsy (FNAB) as a possible predictor of rejection.



   Subjects and methods
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
Eighty-eight patients after their first kidney transplantation, with stabilized graft function, and serum creatinine under 160 µmol/l, treated with cyclosporine A, azathioprine and prednisone were randomized, according to the month of birth, into a withdrawal group (A, n=46), and a control group (B, n=42). Only one graft for the patient in group B was from living donor, 87 grafts were from cadaverous donors. There was no statistical difference in the main characteristic features (Table 1Go) between both groups.


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Table 1. Characteristics of patients in groups A and B

 
In patients of group A, prednisone was gradually withdrawn over a period of 6 months, while the dose of cyclosporin A was adjusted to keep whole blood levels in the upper half of the therapeutic range, and azathioprine dose on a minimum of 1.5 mg/kg/day. The immunosuppressive protocol in patients of group B was not changed. Duration of follow-up after stopping steroids was 12 months.

Rejection was suspected, when serum creatinine increased more than 30 µmol/l. All rejections were confirmed by biopsy assessed according to Banff classification.

FNAB was carried out in a modification after Häyry and Willebrand [8] at the time of randomization. The following signs were evaluated as positive: (i) total corrected increment of infiltrating cells >2.3 compared to peripheral blood, (ii) presence of lymphoblasts and plasmablasts, (iii) expression of HLA-DR on >30% of tubular cells, (iv) expression of ICAM-1 on >10% of tubular cells. Presence of 3–4 signs was taken as immunological activity, 2 signs as suspected immunological activity, 0–1 sign as absence of immunological activity. Patients of group A with immunological activity were treated with a total dose of 1 g of methylprednisolone over a period of 3 days. In the case of a persisting finding in FNAB 1 week after treatment, prednisone withdrawal was not undertaken.

Statistics
Analysis of variance with repeated measure and multiple comparison was used. When the variables did not follow Gaussian distribution, a suitable transformation was applied.



   Results
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
Failure of withdrawal and rejections (Table 2Go)
One patient in group A dropped out for unsuccessful treatment of immunological activity in FNAB. As a result, steroid withdrawal was started in 45 patients. Failure of withdrawal was in four patients (due to rejection in three cases and due to leukopenia in one; these patients were restarted on their original dose of steroids). In this group, one patient died, in month 9 after withdrawal, of liver failure with a functioning graft. No other graft was lost in group A, in group B, one graft was lost due to chronic rejection.


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Table 2. Rejections and graft loss

 
Without rejection and with a functioning graft, 40/45 patients finished the study in group A, all of them free of steroids. In group B, 40/42 patients finished the study without rejection and with a functioning graft.

Three patients in group A (6.6%) and two patients in group B (4.7%) experienced acute rejection in the course of, or after withdrawal (no statistical difference between the groups). Overall, 38% of patients in both groups experienced rejection before starting withdrawal but only one of these in each group had rejection before and after withdrawal.

Changes in serum creatinine (Fig. 1Go)
The mean values of serum creatinine at the beginning of withdrawal and at all intervals of follow-up were not statistically different. In group A, the mean value at 1 year after withdrawal was only non-significantly higher than at the beginning of withdrawal, as in group B.



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Fig. 1. Changes in serum creatinine. Comparison of two curves of laboratory values in group A and group B; A:B, NS. W, withdrawal; M, month.

 

Cholesterol and triglycerides (Fig. 2Go)
The mean values of serum total cholesterol decreased non-significantly after steroid withdrawal in group A, while no change was observed in group B. However, when comparing the two curves of the mean values in both groups, the difference between the groups reached statistical difference (P<0.05). No change in the mean values of serum triglycerides was observed.



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Fig. 2. Changes in serum total cholesterol. Comparison of laboratory values of group A and B; A: B* (P<0,05). W, withdrawal; M, month.

 

Leukocytes (Fig. 3Go)
The mean values of blood leukocytes in both groups were not statistically different at the start of steroid withdrawal, but from the end of withdrawal throughout the follow-up period, the mean values were significantly lower in group A. At the end of follow-up, the mean value in group A was highly significantly lower (P<0.001), compared to the value at the start of withdrawal while, in group B, the course of mean values was not significantly altered. Nevertheless, the mean values in group A remained within normal limits, and only in one patient had withdrawal to be stopped due to leukopenia.



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Fig. 3. Changes in blood leukocytes (x109/l). Comparison of laboratory values of group A and B; A: B***(P<0,05). W, withdrawal; M, month.

 

Fine-needle aspiration biopsy (Table 3Go)
In groups A and B, FNAB was assessed in 42 and 37 patients, respectively. In group A, signs of immunological activity were found in two patients. Both were treated with methylprednisolone, in one the treatment was not successful according to follow-up biopsy, and the patient dropped out of the study. In group B, signs of immunological activity were found in one patient who was not treated with methylprednisolone according to the protocol. Signs of suspected immunological activity were found in three patients in each group. None of the patients with any degree of immunological activity developed rejection later on.


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Table 3. FNAB

 

Blood pressure
At the time of randomization, 38/42 and 39/42 patients in groups A and B, respectively, were treated with antihypertensive drugs. At the end of follow-up, these numbers remained unchanged, but in 7/38 and in 6/39 patients of groups A and B, respectively, the doses of antihypertensive drugs were reduced. The mean values of systolic (141 and 136 mmHg) and diastolic (84 and 83 mmHg) blood pressure in groups A and B, respectively, were not significantly different, and did not change in the course of follow-up.



   Discussion
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
The primary aim of this study was to assess the risk for rejection in the course, and after steroid withdrawal. One known factor with an impact on the frequency of rejection is the timing of withdrawal [9]. When steroids were withdrawn within 12 days after transplantation, the incidence of rejection reached 81% [10], while, when withdrawing steroids at 3 months, rejection was observed in 14–24% [1113]; when steroid withdrawal was undertaken at 1 year, rejection decreased to 0–12% [14,15]. Another factor predicting rejection may be speeding up of steroid withdrawal [16]. In a controlled study [17] where steroids were withdrawn at 6 months, but rather quickly during 1 month, rejection developed in 46% of patients. In our controlled study, rejection was observed in 7% of patients and this result was not statistically different from the control group where rejections were observed in 5% of patients. These data thus confirm the safety of late and gradual withdrawal of steroids. Previous rejections, up to two episodes, were not confirmed in this study as a predicting factor for the development of rejection after withdrawal. This observation is consistent with our former experience with cyclosporin A withdrawal from triple-drug therapy [18].

A beneficial effect of steroid withdrawal on blood cholesterol levels [6,17,19], but not on triglycerides [17], was described. The results of this study support this finding. Although cholesterol levels in our study group decreased only non-significantly, a comparison of the mean cholesterol curves in groups A and B revealed a statistically significant difference.

The beneficial effect of steroid withdrawal on hypertension is rather controversial. While in some studies this effect was confirmed [6,14,19], it was not confirmed in other studies [12,20]. In this study, hypertension was well controlled with mean values of blood pressure within normal limits and this fact may be the main reason why blood pressure was not influenced by steroid withdrawal.

After steroid withdrawal, leukopenia, as a result of the myelodepressive effect of azathioprine in the absence of a myelostimulating influence of steroids, may be expected. In patients with steroid withdrawal, a significant decrease in leukocyte count was present, but the mean values remained within normal limits. Genuine leukopenia appeared in only 1/45 patients (2%); this incidence of leukopenia was much lower, compared to 27% [21] and 38% [14] in other studies.

In only 10% of patients, some degree of immunological activity in FNAB was found and none of these patients developed rejection including one patient in group B who had three signs of activity and was not treated with methylprednisolone. Thus, immunological activity in FNAB was not confirmed as a possible predictive factor for rejection. This finding is in agreement with a previous study [22], which tried to employ FNAB for predicting rejection in patients switched from cyclosporine A to azathioprine 6 months after transplantation. Although immunological activity was found in 50% of patients, a clear correlation with rejection was not demonstrated.



   Conclusion
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 
Steroid withdrawal can be safely done after the first year of transplantation in renal transplant patients treated with triple-drug combination with cyclosporine A and azathioprine, and with excellent graft function. The use of FNAB to predict rejection was not found to be helpful.



   Acknowledgments
 
The study was supported by grant No 3631-3 awarded by the Internal Grant Agency of the Ministry of Health of the Czech Republic.



   Notes
 
Correspondence and offprint requests to: Ivo Matl, Vídenská 1958/9, 14021 Prague 4, Czech Republic. Back



   References
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 

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