Steroid Withdrawal in Liver Transplant Recipients

Progress in Transplantation, Vol 11, No. 3, September 2001 Since the introduction of corticosteroids in the 1960s, this treatment remains an important part of maintenance therapy after orthotopic liver transplantation to prevent graft rejection. Corticosteroids are thought to have multifaceted immunosuppressive properties. In addition to being a foundation in the treatment and prevention of rejection, they are thought to alter cytokine release and function and to regulate T lymphocyte apoptosis. Corticosteroids in particular are associated with many troublesome side effects, including osteopenic bone disease (osteoporosis, pathological fractures, avascular necrosis), hypertension, diabetes, fluid retention, mood swings, capillary fragility and ecchymoses, cataracts, weight gain, hyperlipidemia, adrenal suppression, psychiatric disorders (steroid psychoses), and infections. In recent years, both heart and kidney recipients have been weaned off corticosteroids, which may be in part because of the problems of steroid-induced diabetes, hypertension, and hyperlipidemia after heart and kidney transplantation. Rejection rates of up to 50% with the risk of chronic rejection have made steroid withdrawal controversial in kidney transplant recipients. In the heart transplant population, steroid withdrawal has been successful in up to 80% of the patients, but the risk of chronic rejection in these patients has been prevalent as well. Corticosteroid withdrawal has not been widely practiced in liver transplant recipients despite the presumed lower immunologic potential of liver recipients compared with heart and kidney recipients. Most steroid withdrawal studies after liver transplantation have been done in pediatric patients. Both acute and chronic rejection have been a concern of the withdrawal of steroids. Despite the long-term survival of liver transplant recipients, the long-term complications of chronic immunosuppression remains a major source of morbidity. Many studies have reported a reduction in these complications without causing graft loss with steroid reduction and withdrawal. Certain liver diseases with a suspected immunological component such as primary biliary cirrhosis, sclerosing cholangitis, and autoimmune hepatitis may not tolerate the withdrawal of corticosteroids. These diseases may recur after transplantation, and there is at least a theoretical concern that withdrawal of cortico steroids may potentiate this recurrence.