Steroid avoidance protocols in pediatric kidney transplantation

Steroids have been the cornerstone of immunosuppressive therapy since the early days of kidney transplantation. However, side effects of chronic steroid use cause significant morbidity in transplanted patients. In pediatrics the deleterious effects of steroids on linear growth prompted the search for steroid minimization or steroid avoidance protocols. The introduction of induction agents and more potent immunosuppressive drugs such as Tacrolimus and Mycophenolate Mofetil paved the way for the emergence of steroid avoidance protocols. These protocols utilize steroids only in the very early days post-transplant achieving graft survival rates similar to steroid based protocols, while avoiding side effects of chronic steroid use and allowing catch up growth in prepubertal children. The use of steroid avoidance protocols have gained acceptance in recent years with data showing that 51% of pediatric kidney transplant recipients in the United States are free of steroids at 30 days post-transplant. This chapter will review the evolution and current literature on steroid minimization regimens focusing mainly on steroid avoidance protocols. When evaluating such protocols careful consideration should be given to the induction agent and maintenance immunosuppression used and their side effects profile in order to ensure adequate balance between rejection vs. infection and malignancy risk. As steroid avoidance protocols become more widespread there are still questions to be answered regarding long term outcome data and their role in specific patient populations such as high immunologic risk patients and adolescents. As the field of transplant immunosuppression continues to evolve, the final role of steroid avoidance protocols is yet to be determine.