Tacrolimus (FK506), a potent immunosuppressive drug, is today used as a standard baseline therapy after liver transplantation (1, 2). It is highly potent and at the same has only a few side effects. For a long time, corticosteroids have been used as the pillar of immunosuppressive therapy after liver transplantation. However, they have multifarious side effects, such as diabetes, hypertension, altered lipid metabolism, obesity, osteoporosis, and increased infection rate. This explains the trend to reduce corticosteroids after solid organ transplantation (3–5). In addition to this, the impact of steroids on hepatitis C virus (HCV) recurrence still remains unclear (6). This is of particular interest because up to 40% of liver transplantation in Europe and the United States are performed for hepatitis C (7, 8).
We have previously reported on a prospective, randomized, double-blinded trial on early steroid withdrawal performed to create evidence-based data (9). Long-term results generated in such studies are not available. Therefore, patient and graft survival, steroid side effects, and, in particular, long-term course in HCV patients are of interest. In this study, we present the results of a reevaluation of our study patients.
A total of 198 patients were transplanted in our center from February 2000 to July 2004. From these, 110 patients were recruited for the study. Fifty-four patients (49.1%) were randomized to the steroid group and 56 (50.9%) to the placebo group. Patient demographics were comparable in both groups (Table 1).
Five years after orthotopic liver transplantation (OLT), we were able to obtain information regarding patient survival, organ survival, and medication from all patients initially randomized. Dual energy x-ray absorptiometry (DEXA) was performed on 60 patients before OLT (26 in the placebo group vs. 34 in the steroid group) and on 57 patients 5 years after OLT (25 patients in the placebo group vs. 32 in the steroid group).
Twenty-eight (26%) patients died during the 5-year follow-up, 17 (30%) in the placebo group and 11 (21%) in the steroid group. The most common causes of death were hepatocellular carcinoma recurrence (n=4) in the placebo group and sepsis (n=3) in the steroid group. Neither patient (P=0.236) nor graft survival (P=0.509) were different in both groups. In total, eight patients (7.3%) were retransplanted within 5 years, four (7.1%) in the placebo group, and four (7.4%) in the steroid group. Figure 1 shows the Kaplan-Meier estimation of patient and organ survival in both groups.
Immunosuppression 5 Years After OLT
From the 82 remaining patients, 60 are treated with FK506 and only 32 still receive a FK506 monotherapy. Other applied immunosuppressive drugs are cyclosporin, sirolimus, mycophenolate mofetil and azathioprine. Only three patients were on steroid baseline therapy 5 years after OLT (one in the placebo group vs. two in the steroid group).
Acute rejection after initiation of the study medication is comparable in both groups. Steroid-free immunosuppressive therapy lead to a higher rate of chronic rejections (P=0.023; Fig. 2).
Steroid Side Effects
Comparing the respective data before OLT and after 5 years, no differences in the rates of hypertension (58% in the steroid group vs. 65%, P=0.647), diabetes mellitus (23% in the steroid group vs. 32%, P=0.453), and hypercholesterolemia (16% in the steroid group vs. 24%, P=0.412) were observed. While steroids were used (6 months after OLT), statistically significant differences in diabetes (53% in the steroid group vs. 30%; P=0.024) and hypercholesterolemia (41% in the steroid group vs. 10%; P=0.002) were demonstrable.
We could not find statistical differences in osteoporosis rate before and after OLT between the steroid and placebo group (before OLT: seven patients in the steroid group vs. nine patients P=0.434; 5 years after OLT: 5 patients in the steroid group vs. four patients, P=0.624).
Hepatitis C Patients
Hepatitis C patients were equally distributed in both groups, with 14 and 16 patients in the placebo and the steroid group, respectively. The demographics are shown in Table 1. The subgroup analysis of patients with HCV infection resulted in comparable patient survival (P=0.096) and organ survival (P=0.424), absence of fibrosis (P=0.603), or cirrhosis (P=0.647). The influence of baseline steroid use and steroid bolus therapy on the course of HCV infection after OLT was analyzed separately. The rate of patients treated with steroid bolus therapy was comparable in both groups. Although baseline differences in steroid intake in the first 6 months after liver transplantation did not influence recurrent fibrosis or cirrhosis, bolus therapy was associated with rapidly recurrence of cirrhosis in HCV patients (P=0.01; Fig. 3).
Reducing immunosuppressive therapy after liver transplantation is justifiable because of the various side effects of immunosuppressive drugs (10, 11). A number of studies have been performed to find an immunosuppressive regimen with minimal adverse effects and maximum safety (11–13). In particular, steroids cause undesirable metabolic effects such as posttransplant diabetes mellitus and hypertension leading to increased cardiovascular risk, increased infection rate, osteoporosis, and potentially HCV recurrence (14, 15).
This study was set up in 1999, and 1-year results were published in 2007 (9). As stated in the former publication, early tacrolimus monotherapy after liver transplantation is possible with a reduced risk of metabolic side effects compared with combined therapy of tacrolimus and steroids. However, as early as after 12 months, principal metabolic disturbances proved reversible. In the present long-term follow-up, 4½ years after discontinuation of steroid therapy, no differences in the analyzed steroid side effects were observed in both groups. Rates of hypertension, hypercholesterolemia, and posttransplant diabetes mellitus as well as patient and organ survival were not statistically different. Acute rejections were equally distributed in both groups. These results regarding acute rejections are corroborated by various studies (16–19). Chronic rejections occur statistically more often in the placebo group (P=0.02). As to chronic rejection and avoidance of steroids, our results indicate that steroid-free immunosuppressive therapy after liver transplantation is associated with a higher risk of chronic rejection and a reduced safety in the long run. Because there is no other information available, we recommend further investigations on this issue (20).
Osteoporosis is a considerable and primarily late-onset side effect of steroids. However, 4½ years after discontinuation of study medication, no difference was observed in both groups.
There are considerations that steroid-free immunosuppressive therapy in HCV patients leads to a better long-term outcome regarding HCV recurrence (14, 16, 17). Our findings confirm that recirrhosis in HCV patients is promoted by steroid bolus therapy and not by steroid baseline therapy. The reason for this still remains unclear. The interpretation of liver biopsy in HCV-positive patients after liver transplantation is difficult (21, 22). Pathomorphologic analysis shows signs of inflammation and rejection; at the same time, HCV reinfection and acute rejection are accompanied by transaminasemia (23). This leads to the question whether steroid bolus therapy is responsible for HCV reinfection or whether steroid bolus therapy is an indication for a complicated course after OLT with early HCV recurrence (24).
Early tacrolimus monotherapy after OLT is a feasible immunosuppression. However, negative steroid side effects diminish after discontinuation of steroid therapy. Even osteoporosis as a long-lasting adverse effect of steroids is not significantly increased in the long-term outcome. To evaluate the correlation of steroid avoidance and chronic rejections, further investigations are needed.
With regard to HCV patients, the indication of steroid bolus therapy deserves particular scrutiny. Pathologic findings often show evidence of rejection and HCV reinfection at the same time. A critical assessment of risk and benefit of steroid bolus therapy is absolutely necessary.
MATERIALS AND METHODS
Patients and Study Design
Between 2000 and 2004, a prospective, randomized, double-blinded single-center trial comparing early FK506 monotherapy with a combined FK506 and steroids therapy was performed. All patients undergoing liver transplantation for any indication at the University Medical Centre of Mainz between February 2000 and July 2004 and fitting the inclusion criteria (recipient of a transplanted liver for the first time and aged older than 18 years) where included. Patients were excluded because of treatment with steroid in between 6 months before OLT, pregnancy, other immunosuppressive therapy, human immunodeficiency virus infection, allergy, and intolerance of FK506 as well as participation in another clinical trial. All patients who gave their informed consent were randomized directly before liver transplantation.
The study was in accordance with the Declaration of Helsinki, and the approval of the local ethic committee was obtained before the trial was implemented. Patient care and study conduct complied with good clinical practice.
All patients received the same immunosuppressive therapy with FK506 and steroids during the first 2 weeks after liver transplantation. FK506 was used as the basic immunosuppressive therapy and was given to the patients during the whole follow-up. Patients received the first dose within 12 hr after transplantation. Target whole-blood trough level was 10 to 15 ng/mL during the first 6 weeks and 5 to 10 ng/mL thereafter.
Intraoperatively, a steroid bolus of 1000 mg methylprednisolon was given. Methylprednisolon was tapered down during a 2-week period, beginning with 100 mg on day 1 to 12 mg on day 14. After day 14, patients received study medication, placebo or methylprednisolon capsules in a double-blinded way. The steroid group received 12 mg from day 14 until day 60 and 8 mg from day 60 until day 180. No other immunosuppressive therapy was allowed.
Patients underwent protocol liver biopsy 1 year and 5 years after OLT. All episodes of acute rejection were also verified by liver biopsy. If acute rejection was confirmed, patients received 500 mg methylprednisolon per day for 3 days, as steroid bolus therapy. If a biliary ductopenia was seen in screening liver biopsy or liver biopsy because of complications, chronic rejection was ascertained according to the results of the fifth Banff Consensus conference (25).
Four years after ending the trial, we reevaluated patient survival, graft survival, steroid side effects such as hypertension, hypercholesterolemia, posttransplant diabetes, and osteoporosis. Hypertension, hypercholesterolemia, and diabetes were diagnosed according to the guideline of the World Health Organization. Osteoporosis was defined as a T-score of less than 2.5 in the DEXA. DEXA was performed before OLT and between 3 and 5 years after OLT. T-score of the left hip and lumbar region was measured and analyzed.
In addition to this, we analyzed the subpopulation of HCV-positive patients regarding patient survival, graft survival and fibrosis- and cirrhosis-free time (14). HCV reinfection was diagnosed by transaminasemia, high or increasing HCV RNA load, and liver biopsy to confirm inflammation and exclude acute rejection. Fibrosis und cirrhosis were classified according to the fibrosis score of Desmet et al. (26) and Scheuer (27).
The statistic analysis was performed in cooperation with the Institute of Medical Biometrics, Epidemiology and Informatics of the Johannes Gutenberg University Mainz. The initially scheduled sample size of a minimum of 100 patients (50 per treatment group) was based on an estimated difference in incidence of steroid side effects of 15% between the primary study endpoints
Continuous variables were analyzed using the Student's t test or Wilcoxon rank sum test as indicated. Categorical variables were analyzed using chi-square test or Fisher exact test. Time-dependent data were estimated using the Kaplan-Meier method. Statistical significance was defined as P less than or equal to 0.05.
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