Results of steroid withdrawal in renal allograft recipients on low‐dose cyclosporine A, azathioprine and prednisolone

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Abstract
One hundred and five consecutive cadaveric renal allografts have been studied to evaluate a regime of low‐dose cyclosporin A (CsA), azathioprine (AZA) and prednisolone. The objective was to eliminate maintenance prednisolone by 6 months without sacrificing graft survival or adding unacceptable levels of cyclosporin toxicity. Initially all recipients were started on AZA 2 mg/kg/day, CsA 8 mg/kg/d and prednisolone 15–25 mg/d. AZA was maintained at 2 mg/kg/d and the CsA dose was adjusted to maintain a trough whole blood concentration of 300–400 ng/ml after 1 month. The prednisolone dose was reduced by 2.5 mg every 2 wk until it was eliminated, by 4 to 6 months. The 12‐month actuarial graft survivals for primary and non‐primary grafts were 86% and 76% respectively. The 12‐month actuarial patient survival was 95%. Eleven of the 14 graft losses were due to rejection and 3 of the 4 patient deaths were due to infection. The median serum creatinine concentrations at 6 and 12 months post‐transplant were 0.12 mmol/1 and 0.13 mmol/1 respectively. Of the 60 patients who were followed for more than 6 months, 47 (78%) had ceased prednisolone. Twelve patients had restarted prednisolone 4 d to 14.5 months following its cessation; 10 of these recommenced because of rejection, 1 because of recurrent focal glomerulosclerosis and 1 because of a temporary cessation of AZA. Four of these patients again ceased prednisolone a second time. There were no graft losses and all maintained good graft function. Seven of the 10 patients who developed rejection after ceasing prednisolone had a trough whole blood CsA concentration of less than 300 ng/ml at the time of rejection and 8 were receiving AZA at less than 2 mg/kg/d. At the time of assessment, 38 (63%) had ceased maintenance prednisolone, 16 (27%) were receiving triple immunosuppression with a median prednisolone dose of 7.5 mg/d (range 1–12.5 mg/d) and 6 were receiving AZA and prednisolone. In conclusion this protocol allows most renal allograft recipients to safely cease prednisolone without compromising their graft function or survival.