Authors' Reply to Knight and Morris

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We would like to thank the authors Knight and Morris for sharing their interpretation of our article (1). However, to clarify any possible confusion: nowhere in the article, we concluded that “early steroid withdrawal in the first week after transplantation is less safe than withdrawal beyond 3 months after transplantation” as the authors point out in their letter. As far as the interpretation regarding the acute rejection data is concerned, we have merely stated that in the meta-analysis of Knight and Morris (2), “the incidence of acute rejection was increased in the first three groups (steroid avoidance and steroid withdrawal before 7 days and between 7 days and 1 year) but not in the fourth (steroid withdrawal after 1 year).” However, we did not conclude from these observations that it would be “safer to withdraw steroids beyond 1 year posttransplant” (1). The broad and overlapping confidence intervals for the calculated relative risks would indeed not allow for drawing this conclusion, as rightfully pointed out by the authors (2). Moreover, in our article, we state that “although steroid avoidance and withdrawal regimens after kidney transplantation were associated with higher rates of acute rejection, this did not result in inferior patient or graft survival” (1). We want to take this opportunity to reiterate the exact conclusions of our article, which were 3-fold. First, in our opinion, withdrawal of steroids between 3 and 6 months posttransplant can be safely performed in selected patients (and this in contrast to the Kidney Disease: Improving Global Outcomes guidelines [3]). Second, although early discontinuation may be safe in patients who are at low immunologic risk, we believe that markers should be identified and evaluated to correctly identify this subset of patients and—given recent data concerning increased risk of chronic allograft nephropathy after early steroid withdrawal (4)—more studies focusing on long-term outcome should be performed before this approach is promoted as a standard practice care (as in the Kidney Disease: Improving Global Outcomes guidelines [3]). Finally, we are strongly convinced that future studies in this field should focus on long-term renal outcome (and not solely on acute rejection as a surrogate marker), cardiovascular outcome, and patient outcome. Ben Sprangers Yves Vanrenterghem Division of Nephrology Department of Medicine University Hospitals Leuven Leuven, Belgium