Updated metaanalysis of steroid withdrawal in renal transplant patients on calcineurin inhibitor and mycophenolate mofetil

During the 1990s two metaanalysis of randomized clinical trials of steroid withdrawal after renal transplantation showed significant increases in acute rejection episodes and graft failure rates. A recently published metaanalysis of steroid withdrawal in patients on a calcineurin inhibitor and MMF included randomized clinical trials. We have updated this study, searching more publications during the last 2 years. Finally, the same six trials were included, four in patients receiving cyclosporine and two tacrolimus. Risk ratio (RR) for acute rejection was 2.28 [95%CI 1.65-3.16, P <.00001], and pooled risk difference (RD) was 0.08 [0.05-0.11, P <.001], indicating that the proportion of patients with acute rejection episodes after prednisone withdrawal was significantly higher compared with controls. RR for graft failure was 0.73 [0.42-1.28, P = .27], and RD was -0.01 [-0.03-0.01, P = .28], indicating that the proportion of patients with graft failure after withdrawal was not significantly different from that of controls. Total cholesterol was significantly lower after steroid withdrawal (weighted mean difference -0.53 mu mol/L [-0.70--0.36, P <.0001]). Renal allograft recipients on triple therapy with a calcineurin inhibitor, MMF, and steroids are at low but significant risk of acute rejection after steroid withdrawal, but do not suffer an increased risk of early graft failure. It is necessary to extend controlled follow-up to confirm graft function stabilization.