Influence of Maintenance Steroids on the Outcomes in Deceased-Donor Kidney Transplant Recipients Exposed to Prolonged Pretransplantation Dialysis

Abstract Background Pre-transplant dialysis duration exerts a graded negative influence on outcomes after kidney transplantation. Higher immune reactivity associated with prolonged dialysis with consequent increased acute rejection could be contributory. Methods Using the Organ Procurement and Transplant Network/United Network of Organ Sharing database, we identified patients ≥18 years of age who received deceased-donor kidney (DDK) transplants from 2000 to 2008 after being on maintenance dialysis for ≥4 years. Patients received induction therapy with rabbit antithymocyte globulin (r-ATG), alemtuzumab, or an interleukin-2 receptor blocker (IL-2B) and were discharged on calcineurin inhibitor (CNI)/mycophenolate mofetil (MMF)–based immunosuppression with or without steroid. Unadjusted and adjusted graft/patient survivals were compared in steroid versus no-steroid groups by induction type. Results A total of 14,459 patients were identified, of which 7,684 received r-ATG (steroid, 6,098; no-steroid, 1,586), 1,292 alemtuzumab (steroid, 362; no-steroid, 930), and 5,483 an IL-2B agent (steroid, 5,107; no-steroid, 376). Adjusted graft survivals were similar for steroid versus no-steroid groups in r-ATG (hazard ratio [HR] 1.10, 95% confidence interval (CI) 0.96–1.26, P = .16), alemtuzumab (HR 0.88, 95% CI 0.65–1.19; P = .40), and IL-2B (HR 0.91, 95% CI 0.73–1.13; P = .38) groups. Adjusted patient survival for steroid versus no-steroid groups was inferior in r-ATG (HR 1.41, 95% CI 1.17–1.71; P < .001) but similar in alemtuzumab (HR 1.05, 95% CI 0.70–1.59; P = .80) and IL-2B (HR 1.17, 95% CI 0.86–1.58; P = .32) groups. Conclusions Our analysis failed to show a graft survival benefit for the addition of steroid to a CNI/MMF-based immunosuppression after induction with r-ATG, alemtuzumab, or an IL-2B agent in DDK recipients exposed to prolonged pretransplantation dialysis.