{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T12:24:06Z","timestamp":1791807846937,"version":"4.3.4"},"reference-count":32,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2024,11,14]],"date-time":"2024-11-14T00:00:00Z","timestamp":1731542400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Center for Advancing Translational Sciences, National Institutes of Health, and the In-stitute for Translational Sciences at the University of Texas Medical Branch","award":["KL2TR001441"],"award-info":[{"award-number":["KL2TR001441"]}]},{"name":"National Center for Advancing Translational Sciences, National Institutes of Health, and the In-stitute for Translational Sciences at the University of Texas Medical Branch","award":["1 D34HP49234-01-00"],"award-info":[{"award-number":["1 D34HP49234-01-00"]}]},{"name":"Department of Health and Human Services, HRSA, UTMB Center of Excellence for Professional Advancement and Research","award":["KL2TR001441"],"award-info":[{"award-number":["KL2TR001441"]}]},{"name":"Department of Health and Human Services, HRSA, UTMB Center of Excellence for Professional Advancement and Research","award":["1 D34HP49234-01-00"],"award-info":[{"award-number":["1 D34HP49234-01-00"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Background\/Objectives: With kidney transplant immunosuppression, physicians must balance preventing rejection with minimizing infection and malignancy risks. Steroids have been a mainstay of these immunosuppression regimens since the early days of kidney transplantation, yet their risks remain debated. Our study looks at the clinical outcomes of patients undergoing early steroid withdrawal (ESW) vs. steroid continuous (SCI) maintenance immunosuppression in adult kidney transplant recipients. Methods: A retrospective case-control study, utilizing propensity score-matching, was performed using the US Collaborative Network Database within TriNetX to evaluate renal transplant outcomes at one year in first-time kidney transplant adult patients (&gt;18 years old) who were prescribed an ESW regimen (no steroids after post-transplant day 7 with maintenance tacrolimus [tac] + mycophenolic acid [MMP]\/mycophenolate mofetil [MMF]) vs. SCI (tac + MMF\/MMP + prednisone). Cohorts were matched on demographics, comorbidities, previously described risk factors for rejection, and induction immunosuppression. Primary outcomes included viral infections, pyelonephritis, and sepsis. Secondary outcomes included renal transplant rejection, death-censored allograft failure (eGFR &lt; 15 mL\/min), patient mortality, delayed graft function, and diabetes mellitus. Results: A total of 2056 patients were in each cohort after matching (mean age: 50.7\u201351 years, 17.9\u201320.0% African American, 60\u201360.6% male.) The SCI cohort had a significantly higher cumulative incidence of composite viremia (18 vs. 28.1%, ESW vs. SCI, p &lt; 0.01) driven by CMV, EBV, and BK virus. Post-transplant diabetes mellitus was significantly higher in the SCI cohort (3.21% vs. 5.49%, ESW vs. SCI, p &lt; 0.01). Delayed graft function was also higher in the SCI cohort (19.55% vs. 22.79%, ESW vs. SCI, p &lt; 0.01). Pyelonephritis (2.3 vs. 4.91%, ESW vs. SCI, p &lt; 0.01) and sepsis (2.15 vs. 5.95%, ESW vs. SCI, p &lt; 0.01) were higher in the SCI cohort. Rejection rates were similar between ESW and SCI (29 vs. 31%, ESW vs. SCI, p = 0.41). There were significantly higher incidences of graft failure (4.9 vs. 9.9%, ESW vs. SCI, p &lt; 0.01) and mortality (0.8 vs. 2.1%, ESW vs. SCI, p &lt; 0.01) in the SCI cohort. Conclusions: This well-matched case-control study suggests that ESW is associated with lower infectious outcomes, mortality, and graft failure without increasing rejection risk, supporting the potential benefits of ESW in kidney transplant patients.<\/jats:p>","DOI":"10.3390\/jpm14111106","type":"journal-article","created":{"date-parts":[[2024,11,14]],"date-time":"2024-11-14T09:14:31Z","timestamp":1731575671000},"page":"1106","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Precision in Immune Management: Balancing Steroid Exposure, Rejection Risk, and Infectious Outcomes in Adult Kidney Transplant Recipients"],"prefix":"10.3390","volume":"14","author":[{"given":"Avery N.","family":"Koi","sequence":"first","affiliation":[{"name":"John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John C.","family":"Johnson","sequence":"additional","affiliation":[{"name":"John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Trine L.","family":"Engebretsen","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Multiorgan Transplant and Hepatobiliary Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9426-4290","authenticated-orcid":false,"given":"Muhammad A.","family":"Mujtaba","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Transplant Nephrology, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alfred Scott","family":"Lea","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Infectious Disease, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0645-7621","authenticated-orcid":false,"given":"Heather L.","family":"Stevenson","sequence":"additional","affiliation":[{"name":"Department of Pathology, Division of Transplant Pathology, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2509-0877","authenticated-orcid":false,"given":"Michael L.","family":"Kueht","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Multiorgan Transplant and Hepatobiliary Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0609, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,11,14]]},"reference":[{"key":"ref_1","unstructured":"UNOS (2024). UNOS Data and Transplant Statistics: Organ Donation Data, UNOS. Available online: https:\/\/unos.org\/data\/."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1001\/jamasurg.2020.6929","article-title":"Early Corticosteroid Cessation vs Long-term Corticosteroid Therapy in Kidney Transplant Recipients: Long-term Outcomes of a Randomized Clinical Trial","volume":"156","author":"Woodle","year":"2021","journal-title":"JAMA Surg."},{"key":"ref_3","first-page":"CD005632","article-title":"Steroid avoidance or withdrawal for kidney transplant recipients","volume":"2016","author":"Haller","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1097","DOI":"10.1136\/bmj.286.6371.1097","article-title":"High versus \u201clow\u201d dose corticosteroids in recipients of cadaveric kidneys: Prospective controlled trial","volume":"286","author":"Papadakis","year":"1983","journal-title":"Br. Med. J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.1016\/S0022-3476(87)80050-1","article-title":"Renal transplantation without steroids","volume":"111","author":"Salaman","year":"1987","journal-title":"J. Pediatr."},{"key":"ref_6","first-page":"885","article-title":"Increased Immunosuppressive Vulnerability in Elderly Renal Transplant Recipients","volume":"69","author":"Ojo","year":"2000","journal-title":"Transplantation"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"3006","DOI":"10.1016\/S0140-6736(16)32187-0","article-title":"Rabbit-ATG or basiliximab induction for rapid steroid withdrawal after renal transplantation (Harmony): An open-label, multicentre, randomised controlled trial","volume":"388","author":"Thomusch","year":"2016","journal-title":"Lancet"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1093\/ndt\/gfad130","article-title":"Excellent efficacy and beneficial safety during observational 5-year follow-up of rapid steroid withdrawal after renal transplantation (Harmony FU study)","volume":"39","author":"Stumpf","year":"2023","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_9","unstructured":"(2024, May 13). TriNetX 2024. Available online: https:\/\/trinetx.com\/."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"ooad035","DOI":"10.1093\/jamiaopen\/ooad035","article-title":"A global federated real-world data and analytics platform for research","volume":"6","author":"Palchuk","year":"2023","journal-title":"JAMIA Open"},{"key":"ref_11","unstructured":"TriNetX Admin (2024, November 09). TriNetX Real-World Evidence Platform Validates Outcomes of Randomized Clinical Trials. TriNetX, Available online: https:\/\/trinetx.com\/press-releases\/real-world-evidence-platform-validates-outcomes-of-randomized-clinical-trials\/."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"252","DOI":"10.4239\/wjd.v9.i12.252","article-title":"Using real world data to assess cardiovascular outcomes of two antidiabetic treatment classes","volume":"9","author":"Stapff","year":"2018","journal-title":"World J. Diabetes"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1007\/s40620-016-0354-x","article-title":"Profiling risk for acute rejection in kidney transplantation: Recipient age is a robust risk factor","volume":"30","author":"Rana","year":"2017","journal-title":"J. Nephrol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2213","DOI":"10.2215\/CJN.01790215","article-title":"Risk stratification for rejection and infection after kidney transplantation","volume":"10","author":"Schiesser","year":"2015","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1111\/tri.12205","article-title":"Pretransplant identification of acute rejection risk following kidney transplantation","volume":"27","author":"Lebranchu","year":"2014","journal-title":"Transpl. Int."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Oweira, H., Ramouz, A., Ghamarnejad, O., Khajeh, E., Ali-Hasan-Al-Saegh, S., Nikbakhsh, R., Rei\u00dffelder, C., Rahbari, N., Mehrabi, A., and Sadeghi, M. (2022). Risk factors of rejection in renal transplant recipients: A narrative review. J. Clin. Med., 11.","DOI":"10.3390\/jcm11051392"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"13","DOI":"10.2215\/CJN.13961119","article-title":"Medical therapies to reduce delayed graft function and improve long-term graft survival: Are we making progress?","volume":"15","author":"Lim","year":"2020","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1637","DOI":"10.1001\/jama.2015.13480","article-title":"The propensity score","volume":"314","author":"Haukoos","year":"2015","journal-title":"JAMA"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2096","DOI":"10.1111\/ajt.12313","article-title":"Association Between Steroid Dosage and Death with a Functioning Graft After Kidney Transplantation","volume":"13","author":"Opelz","year":"2013","journal-title":"Am. J. Transplant."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e354","DOI":"10.1097\/TXD.0000000000000794","article-title":"Early Steroid Withdrawal Compared with Standard Immunosuppression in Kidney Transplantation\u2014Interim Analysis of the Amsterdam-Leiden-Groningen Randomized Controlled Trial","volume":"4","author":"Bakker","year":"2018","journal-title":"Transplant. Direct"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"494","DOI":"10.2215\/CJN.08630811","article-title":"Ten-year outcome after rapid discontinuation of prednisone in adult primary kidney transplantation","volume":"7","author":"Rizzari","year":"2012","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2590","DOI":"10.1097\/TP.0000000000001756","article-title":"Rapid Discontinuation of Prednisone in Kidney Transplant Recipients: 15-Year Outcomes from the University of Minnesota","volume":"101","author":"Serrano","year":"2017","journal-title":"Transplantation"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"900","DOI":"10.1097\/TP.0000000000002191","article-title":"The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation","volume":"102","author":"Kotton","year":"2018","journal-title":"Transplantation"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/TP.0b013e3181c518cc","article-title":"Steroid avoidance or withdrawal after renal transplantation increases the risk of acute rejection but decreases cardiovascular risk. A meta-analysis","volume":"89","author":"Knight","year":"2010","journal-title":"Transplantation"},{"key":"ref_25","first-page":"CD005632","article-title":"Steroid avoidance or withdrawal for kidney transplant recipients","volume":"2009","author":"Pascual","year":"2009","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e1433","DOI":"10.1097\/TXD.0000000000001433","article-title":"Effects of Delayed Graft Function on Transplant Outcomes: A Meta-analysis","volume":"9","author":"Li","year":"2023","journal-title":"Transplant. Direct"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1111\/tri.13654","article-title":"Relevance of KDPI value and acute rejection on kidney transplant outcomes in recipients with delayed graft function\u2014A retrospective study","volume":"33","author":"Buxeda","year":"2020","journal-title":"Transpl. Int."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1681\/ASN.2019040416","article-title":"Early Steroid Withdrawal in Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function","volume":"31","author":"Bae","year":"2020","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1483","DOI":"10.1007\/s40262-019-00771-3","article-title":"Population Pharmacokinetics of Mycophenolic Acid Co-Administered with Tacrolimus in Corticosteroid-Free Adult Kidney Transplant Patients","volume":"58","author":"Rong","year":"2019","journal-title":"Clin. Pharmacokinet."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1046\/j.1523-1755.2002.00531.x","article-title":"Glucocorticoids Interfere with Mycophenolate Mofetil Bioavailability in Kidney Transplantation","volume":"62","author":"Cattaneo","year":"2002","journal-title":"Kidney Int."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Nourbakhsh, N., Ekberg, J., Skov, K., Peters, C.D., \u00d8zbay, A., Lindner, P., and Buus, N.H. (2021). Effects of Corticosteroid Treatment on Mycophenolic Acid Exposure in Renal Transplant Patients-Results from the SAILOR Study. Front. Pharmacol., 12.","DOI":"10.3389\/fphar.2021.742444"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"915","DOI":"10.1007\/s40266-024-01147-4","article-title":"Assessing Long-Term Adverse Outcomes in Older Kidney Transplant Recipients: A Propensity Score-Matched Comparison of Early Steroid Withdrawal Versus Continuous Steroid Immunosuppression Using a Large Real-World Database","volume":"41","author":"Johnson","year":"2024","journal-title":"Drugs Aging"}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/14\/11\/1106\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:32:28Z","timestamp":1760113948000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/14\/11\/1106"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,11,14]]},"references-count":32,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2024,11]]}},"alternative-id":["jpm14111106"],"URL":"https:\/\/doi.org\/10.3390\/jpm14111106","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,11,14]]}}}