Prednisone Avoidance After Abdominal Solid Organ Transplantation: A Narrative Review

Steroids have been a foundation of immunosuppressive regimens in solid organ transplantation. However, long-term steroid exposure is associated with a number of adverse effects that increase patient morbidity and mortality, contribute to patient nonadherence, and add significant economic burden. Avoidance of prednisone (AoP) minimizes prednisone-related complications but potentially increases the risk of acute rejection and decreases graft survival. We conducted a narrative review of the risks and benefits of AoP, focusing on randomized studies, large registry reports, and meta-analyses. In low-risk kidney transplant recipients, some, but not all, studies report increased early rejection with AoP; however, steroid-resistant rejection is not increased, and there is no difference between maintenance prednisone and AoP in recipient, graft, and death-censored graft survival. Additionally, AoP and maintenance prednisone have similar outcomes in some "high-risk" groups (eg, African Americans); for others (eg, high percent reactive antibody), the data are mixed. The benefits of AoP include decreased new-onset diabetes mellitus, a better metabolic profile, improved bone mineral density, decreased fractures, decreased cardiovascular risk, and, in children, improved growth. In pancreas transplantation, historically higher rates of rejection have likely served as a barrier to steroid minimization, although studies suggest that AoP is feasible in low immunologic risk recipients. There are less data on avoidance protocols in liver transplantation, where prednisone dosing has traditionally been lower. Avoidance may have similar or even added benefits to those mentioned previously. There is a need for additional large randomized trials to better define risks and benefits in these situations.