Patients requiring steroid sparing or avoidance protocols may include those with:
- history/risk of steroid induced psychosis
- patients at high risk of metabolic complications of steroids
Often steroid withdrawal and avoidance protocols used T-cell depleting agents as induction. Recent evidence (HARMONY Trial) suggests that in a low risk group, the 1 year outcomes with steroid withdrawal at 7 days are excellent, using basiliximab as induction. Another RCT demonstrated double the risk of chronic allograft nephropathy at 5 years in early steroid withdrawal and a higher rate of mild rejections. Moreover, if recurrent glomerulonephritis is a concern, caution should be urged with using a rapid steroid taper.
Steroid-sparing protocol (Based on HARMONY Trial)
- Basiliximab, tacrolimus and MMF as standard.
The HARMONY study used 500mg prednisolone at day 0 followed by 100mg on day 1, 75mg on day 2, 50mg on day 3, and 25mg per day on days 4-7.
- Steroids were then stopped completely at day 8.
Steroid avoidance protocol
If there was a definite history of steroid exacerbated psychosis and on risk/balance avoidance of steroid was felt to be paramount. Most complete steroid avoidance regimes in the literature have employed T-cell depleting agents for induction.
- ATG or Alemtuzumab (Campath) for induction – as per immunosuppression section. We generally use ATG as our T-cell depleting agent of choice.
- Despite being called steroid avoidance, these have protocols generally used IV methylprednisolone prior to ATG/Alemtuzumab (Campath) on day 0 and 1. If absolute steroid avoidance is necessary, this should be agreed with a consultant psychiatrist and an individulised regime devised for that patient, weighing up risks of using/not-using any steroid.
- Ensure tacrolimus level of 10-12 early on.