Long term follow up of steroid-free immunosuppression in Egyptian living donor kidney transplant recipients

Background: Steroids have been a part of any immunosuppressive regimen since the beginning of kidney transplantation because of their anti-inflammatory and immunosuppressive property. Steroids have many adverse effects include worsening hypertension, worsening dyslipidemia, new-onset diabetes, osteoporosis, avascular necrosis and susceptibility to infection. With the availability of better immunosuppressive drugs, many centers have successfully performed corticosteroid free transplantation. The aim of this study was to compare the outcomes of steroid free regimen with steroid based regimen in Egyptian kidney transplant recipients, and their impact on both graft and patient survival. Patients and methods: This retrospective case control study included 480 Egyptian kidney transplant recipients, who underwent transplantation at Urology and Nephrology Center, Mansoura University, Egypt, in the period between 2004 and 2013. They included 2 groups; group I: 240 kidney transplant recipients maintained on a steroid–free immunosuppression regimen [Tacrolimus (Tac)+ mycophenolate mofetil (MMF)], in whom steroids were removed after obtaining a satisfactory Tac trough level 5-10 ng/ml and group II: 240 kidney transplant recipients of matched age, sex and duration of follow up, maintained on a steroid containing immunosuppression regimen. Studied parameters for recipients included; age, sex, original kidney disease, pre-transplant data, immunosuppression, post-transplant complications, rejection episodes, patient and graft survival. Results: The total dose of steroid in the first 3 months post-transplant was 2.55±1.39 gm in group I, vs 4.0±1.67 gm in group II, p<0.0001. There was no significant difference as regards the frequency of acute rejections; while acute humoral rejection was significantly higher in group II (7%), than in group I (1.7%), p=0.0004. Post-transplant viral infections, hypertension and diabetes mellitus were significantly higher in group II (11.6%, 29.6% and 6.6%), than in group I (5.8%, 19.2% and 2.5%), (p=0.026, p=0.009 and p=0.031). Patient and graft survivals were comparable in both groups; living with functioning graft (94.58% vs 91.66%), living on dialysis (5% vs 6.25%), died with functioning graft (0.42% vs 1.67%) or died with failed graft (none vs 0.42%). Also, serum creatinine and creatinine clearance levels were comparable in both groups (1.68±1.67 vs 1.64±1.51 mg/dl) and (83.1 ± 33.9 vs 77.5± 29.9 ml/min). The one year cost of steroid in group II was 1.6 folds that in group I, FK 0.9 folds and MMF 2 folds (total cost 1.15 folds). Conclusion: Patient and graft survivals were comparable in steroid-free and steroid based renal transplantation groups, while post-transplant viral infections, hypertension and diabetes mellitus were higher in steroid-based regimen.