Kidney Transplant Survival After Early Corticosteroid Withdrawal: Impact of African American Race.

Abstract

Background: We sought to compare outcomes related to transplant survival between AA and non-AA recipients after early corticosteroid withdrawal (CSW), and to contrast these outcomes with AA and non-AA patients maintained on corticosteroids (CSM) after kidney transplantation. Methods: We analyzed 405 consecutive solitary kidney recipients from 1/06 to 12/11, after excluding 5 patients with early death or graft thrombosis. All patients received 5 days of I.V. steroids along with tacrolimus/mycophenolate mofetil maintenance therapy. CSW was undertaken after 5 days in 269/405 (66%) patients. The remaining 136 CSM patients were considered higher risk due to delayed graft function, high HLA antibody sensitization, or previous transplant failure. AAs were similarly represented in the CSW and CSM groups (44% vs. 47%). Patient and allograft survival between races within each steroid group were analyzed using Kaplan-Meier methodology and Cox regression analysis. Results: Within the CSM group, there was no statistical difference in graft survival between AA and non-AA recipients (Figure 1a). Alternatively, AA’s exhibited worse survival in the CSW cohort, with a relative decline manifesting after three years post-transplantation (Figure 1b). This was despite similar long term acute rejection rates in AAs and non-AAs in the CSW group (25% vs. 19%, p=ns). Within the CSW group, AA recipients had a longer median dialysis vintage (62 mos vs. 12 mos, p<0.001), more deceased donor (DD) transplants (82% vs. 39%, p<0.001), and more HLA mismatches (4.48±1.48 vs. 3.42±2.00, p<0.001). After controlling for these differences, AA race did not independently predict allograft loss, but DD transplant did (HR: 2.83, 95%CI: 1.22-6.58, p=0.016). Conclusion: Among a large cohort of kidney recipients who underwent CSW, AA recipients had inferior allograft survival beyond three years. However, donor source appeared to drive differences seen between AA and non-AA recipients. Disparities in access to living donor kidney transplanatation may determine differences in outcomes after corticosteroid withdrawal.Figure: No Caption available.