Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding of outcome assessment) and by imprecise results (small trials with few patients and outcome events).
A Cochrane review [Abstract] 1 included 16 studies with a total of 1347 subjects. 10 trials that assessed complete postoperative glucocorticosteroid avoidance (excluding intra-operative use and treatment of rejection) vs short-term glucocorticosteroids (n=782) and 6 trials that assessed short-term glucocorticosteroids vs long-term glucocorticosteroids (n=565). Overall, we found no statistically significant difference for mortality, graft loss including death, or infection when glucocorticosteroid avoidance or withdrawal was compared with glucocorticosteroid-containing immunosuppression T1. Acute rejection and glucocorticosteroid-resistant rejection were more frequent when glucocorticosteroid avoidance or withdrawal was compared with glucocorticosteroid-containing immunosuppression (RR 1.33, 95% CI 1.08 to 1.64; moderate-quality evidence; and RR 2.14, 95% CI 1.13 to 4.02; very low-quality evidence). Diabetes mellitus and hypertension were less frequent when glucocorticosteroid avoidance or withdrawal was compared with glucocorticosteroid-containing immunosuppression (RR 0.81, 95% CI 0.66 to 0.99; low-quality evidence; and RR 0.76, 95% CI 0.65 to 0.90; low-quality evidence).
| Outcome | Relative effect (95% CI) | Assumed risk = glucocorticosteroid-based immunosuppression | Corresponding risk - intervention = No glucocorticosteroid | Number of participants (studies) |
|---|---|---|---|---|
| Mortality | 1.15(0.93 to 1.44) | 204/1000 | 234/1000(189 to 293) | 1323(15) |
| Graft loss incl. death | 1.16(0.91 to 1.48) | 218/1000 | 253/1000(198 to 322) | 1002(11) |
| Acute rejection | 1.33(1.08 to 1.64) | 194/1000 | 257/1000(209 to 317) | 1347(16) |
| Infection | 0.88(0.73 to 1.05) | 402/1000 | 354/1000(293 to 422) | 778(8) |
A analysis 2 included 4184 adult simultaneous liver-kidney recipients on tacrolimus-based regimens at 1 year post-transplant. The use of steroid-sparing regimens increased post-transplant, from 16.1% at discharge to 88.0% at 5 years. In multivariate analysis, use of a steroid-sparing regimen at 1 year was associated with a 21% decreased risk of mortality compared to steroid-containing regimens and 20% decreased risk of liver graft failure, without differences in kidney graft loss risk.
Date of latest search: 11 December 2015
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