Werbel WA, et al. Poster #331. Presented at: American Transplant Congress; May 30 to June 1, 2020. (virtual meeting).
Steroid withdrawal linked to graft rejection in kidney transplant recipients with HIV
For recipients with HIV, early steroid withdrawal was associated with increased odds of acute graft rejection 1 year after kidney transplantation, according to research presented at the American Transplant Congress.
“Kidney transplant has been proven to be safe and effective for persons with HIV and end-stage renal disease with excellent long-term patient and graft survival,” William A. Werbel, MD, of Johns Hopkins University, said during his presentation. “Acute rejection has however been demonstrated to be more common in HIV-positive vs. HIV-negative recipients for as yet unclear reasons.”
Werbel argued that while corticosteroids have been a “longstanding cornerstone in maintenance immunosuppression after transplant and are potent anti-rejection agents,” these are also associated with multiple cardiometabolic and infectious complications after kidney transplantation. Further, some of these complications overlap with common comorbidities in the general HIV population.
Therefore, Werbel suggested, “It is theoretically attractive to limit exposure to corticosteroids in HIV[-positive] recipients through practices such as early steroid withdrawal, which is practiced in about 30% of the general kidney transplant population.”
To examine the relationship between early steroid withdrawal (defined as discharge without steroid maintenance) and acute rejection, researchers used data from the Scientific Registry of Transplant Recipients, including 1,123 recipients who had no rejection or graft loss during transplant hospitalization and who were discharged on calcineurin inhibitors and mycophenolate. Patients were further categorized by whether they underwent early steroid withdrawal (20.2%) or received standard of care, with Werbel noting that early steroid withdrawal utilization is lower for kidney transplant recipients with HIV than in recipients without HIV.
At 6 months, the researchers found early steroid withdrawal was associated with a 62% higher odds of acute rejection. At 1 year, the practice was associated with a 57% higher odds. According to Werbel, these increased odds of rejection exist despite lower risk profiles and more transplantation with kidneys from living donors.
“Early steroid withdrawal utilization varies widely across centers without clear rationale based upon ascertainable variables in the Scientific Registry of Transplant Recipients,” he said.
He suggested that tailoring early steroid withdrawal utilization to the individual patient may be a potential intervention to improve the quality of care, citing examples of reducing both hospitalizations and complications related to acute rejection.