Degree of corticosteroid treatment within the first 2 months of renal transplantation has a strong influence on the incidence of osteonecrosis of the femoral head

Figures & data

Table 1.  Previous reports on avascular necrosis (AVN) after renal transplantation

Authors	Immune suppressor	Onset of AVN (months)
Chatterjee et al. 1976	A	–
Harrington et al. 1971	A	3–29
Patton and Plaff 1988	A or C	mean 15
Tang et al. 2000	A or C	6–121
Pierides et al. 1975	Not shown	5–35

A: azathioprine and C: cyclosporine Diagnosis of AVN was based on plain radiographs in all studies, except for Tang et al. (2000) where MRI was used. All authors except Chatterjee et al. found that the dose of steroid was important for the risk of developing AVN.

Protocol for oral steroid administration. From the day after surgery, prednisolone (50 mg) was administered orally for 7 days (from March 1989 through November 1996), or for 3 days (after December 1996). After that, the oral dose was tapered down to 40, 30, 25, 20, and 17.5 mg every 7 days, and the maintenance dose of 10 mg was attained by the sixth week.

Table 2. Relationship between the type of immune suppressor and the dose of steroid administered

Period (weeks)	Tacrolimus (g)	Cyclosporine (g)	P-value
2	0.74 (0.39–4.5)	0.92 (0.33–6.3)	< 0.001
4	1.3 (0.64–11.5)	1.5 (0.59–8.3)	< 0.001
6	1.6 (0.78–11.6)	1.9 (0.79–8.7)	< 0.001
8	2.0 (0.92–12.8)	2.0 (0.92–12.8)	< 0.001

Wilcoxon rank sum test

Table 3. Relationship between immune suppressor and development of AVN. Adjusted for age, sex, acute rejection, and steroids at 8 weeks

			Crude		Adjusted
	AVN n (%)	No AVN n (%)	OR (95% CI)	P-value	OR (95% CI)	P-value
Cyclosporine	30 (81)	78 (69)	1		1
Tacrolimus	7 (19)	35 (31)	0.52 (0.20–1.3)	0.2	0.67 (0.24–1.9)	0.5

Table 4. The relationship between development of AVN and dose of steroids. Adjusted for age, sex, acute rejection, tacrolimus and cyclosporine

				Crude		Adjusted
Period (weeks)	Dose (mg)	AVN n	No AVN n	OR (95% CI)	P-value	OR (95% CI)	P-value
2	≤550	7	39	1		1
	≥650	17	39	2.4 (0.91–6.5)	0.08	2.2 (0.72–6.9)	0.2
	>650	13	35	2.0 (0.72–5.6) (p=0.2)	0.2	2.1 (0.59–7.2) (p=0.3)	0.3
4	≥895	5	39	1		1
	≤1130	22	41	4.2 (1.4–12)	0.008	4.2 (1.2–15)	0.02
	>1130	10	33	2.3 (0.71–7.4) (p = 0.2)	0.2	2.2 (0.51–9.4) (p = 0.3)	0.3
6	≤1165	6	38	1		1
	≤1487.5	20	38	3.3 (1.2–9.2)	0.02	3.4 (1.1–11	0.04
	>1487.5	11	37	1.8 (0.62–5.5) (p = 0.4)	0.3	1.8 (0.42–8.1) (p = 0.4)	0.44
8	≤1400	4	38	1		1
	≤1795	18	40	4.3 (1.3–14)	0.02	5.6 (1.4–23)	0.02
	>1795	15	35	4.0 (1.2–13) (p = 0.04)	0.02	7.4 (1.5–36) (p = 0.02)	0.01