Background
Steroid avoidance in immunosuppression regimes after solid organ transplantations is feasible without hindering graft outcome or introducing complications. In vascular composite tissue allotransplantations (VCA), however, discharge of steroids is treated with caution, due to the various types of tissues involved and the associated belief of high immunogenicity of skin. In this study we present our experience with steroid withdrawal in 5 VCA recipients.
Methods
Between 2009 and 2011 we performed 4 face and one bilateral hand transplantations at our institution. Induction therapy consisted of mycophenolate mofetil (MMF), anti-thymocyte globulin and methylprednisolone bolus with subsequent tapering. Maintenance immunosuppression consisted of tacrolimus, MMF and prednisone taper. Patients’ records were reviewed with special focus on immunosuppression regimes, rejection episodes, biopsy results, blood levels of drugs and inflammatory markers (Tacrolimus, Cyclex and CRP) as well as metabolic and infectious complications.
Results
Mean follow-up was 37.6 months (median=34 months, range 28 -58 months). In all patients, steroids were withdrawn in the first year after transplantation. Biopsy-proven graft rejections occurred 2, 1, 2, 3 and 2 times in patients 1 to 5, respectively, and were successfully overcome with means of increased maintenance immunosuppression or temporary steroid applications. The incidence and severity of rejection episodes did not increase after steroid withdrawal, but were associated with Tacrolimus blood levels below 4ng/mL. Metabolic complications included 2 new-onset diabetes mellitus, of which one revealed preexisting risk factors and the other quick insulin independency.
Conclusion
Steroid withdrawal in VCA recipients is safe and effective. Rejection episodes did not increase and were manageable with common means such as elevated maintenance immunosuppression or short-term steroid applications.