Steroid withdrawal protocols are increasingly used in kidney transplantation. However, sensitized patients considered high immune risk are maintained on steroid by many centers. It is unclear whether there is a threshold level of sensitization at which survival benefits for steroid use emerge.

Using UNOS database, we identified patients ≥18 years who received deceased donor kidney (DDK) transplants from 2000-2008 after antibody induction and discharged on a calcineurin inhibitor(CNI)/ mycophenolate mofetil(MMF) based regimen with or without steroid. Patients were divided into 3 classes based on peak panel reactive antibody (PRA) titers: 0-30%; 31-60% and >60%. Using a Cox model, unadjusted and adjusted (by including confounders) graft and patient survivals were calculated for steroid vs.no steroid groups in each PRA class.

Distribution of 42,851 study patients by PRA class were as follows: 0-30%, n=32,617 (steroid= 25,218, no steroid= 7399); 31-60%, n= 4345 (steroid=3495, no steroid=850); >60%, n=5889 (steroid=4966, no steroid 923). Graft failure and patient death risks for steroid vs. no steroid groups by PRA class are shown in the table.

In summary, our analysis showed association of higher death with functioning graft in 0-30% PRA group and improved death-censored graft survival in >60% PRA group for steroid addition to CNI/MMF maintenance regimen following antibody induction in DDK transplant recipients. Enhanced immunosuppression associated with steroid addition may not be needed to minimize immunological allograft injury in the former group and could be adding to adverse patient outcomes. In the latter group, the benefits of steroids on reducing allograft immune injury could be exceeding any adverse influence on patient outcomes. Our results favor steroid maintenance in highly sensitized but not in absent/minimally sensitized DDK transplant recipients.

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