Corticosteroids and Kidney Transplantation

Abstract

The Karolinska Institute awarded Dr. Philip Hench a Nobel Prize in the 1950s for treating a patient who had rheumatoid arthritis with corticosteroids. In the 1950s, physicians saw corticosteroids as “miracle drugs” that offered dramatic relief for a diverse group of diseases. Physicians saw extraordinary benefits, such as rheumatoid arthritis patients’ throwing away their crutches or resolution of anaphylactic reactions. The medical community was delighted. The euphoria resulted in the uncritical use of these new agents. However, before long, the medical profession saw the downside of corticosteroid therapy with its diverse chronic toxicities. This two-edged sword has had an impact on solid-organ transplantation from its start in the 1960s until the present day. In the early 1960s, Goodwin and Mims (1) reported that they had used corticosteroids to reverse acute rejection in a living-donor kidney transplant recipient. Starzl and Marchioro (2), in 1963, confirmed the efficacy with corticosteroids and the “almost miracle” effect. On the basis of a limited experience with living-donor transplantation, he suggested that a 100-mg/d dose as prophylaxis against early postoperative acute rejection was superior to treatment with 30 mg/d. One patient on the higher dosage did not have an acute rejection, whereas two on the lower schedule did. Today, these numbers are incredibly small, but we must remember that kidney transplant patients in the early 1960s were too few for any statistical analysis. To his credit, Starzl included a contemporaneous control group ( n = 2) for comparison. Such a design often is absent even in current studies. Perhaps more remarkable for 1963, Starzl expressed concerns that the …