In:
Medical Decision Making, SAGE Publications, Vol. 37, No. 7 ( 2017-10), p. 827-843
Abstract:
Background. Corticosteroids used as immunosuppressants to prevent acute rejection (AR) and graft loss (GL) following kidney transplantation are associated with serious cardiovascular and other adverse events. Evidence from short-term randomized controlled trials suggests that many patients on a tacrolimus-based immunosuppressant regimen can withdraw from steroids without increased AR or GL risk. Objectives. To measure the long-term tradeoff between GL and adverse events for a heterogeneous-risk population and determine the optimal timing of steroid withdrawal. Methods. A discrete event simulation was developed including, as events, AR, GL, myocardial infarction (MI), stroke, cytomegalovirus, and new onset diabetes mellitus (NODM), among others. Data from the United States Renal Data System were used to estimate event-specific parametric regressions, which accounted for steroid-sparing regimen (avoidance, early 7-d withdrawal, 6-mo withdrawal, 12-mo withdrawal, and maintenance) as well as patients’ demographics, immunologic risks, and comorbidities. Regression-equation results were used to derive individual time-to-event Weibull distributions, used, in turn, to simulate the course of patients over 20 y. Results. Patients on steroid avoidance or an early-withdrawal regimen were more likely to experience AR (45.9% to 55.0% v. 33.6%, P 〈 0.05) and GL (51.5% to 68.8% v. 37.8%, P 〈 0.05) compared to patients on steroid maintenance. Patients in 6-mo and 12-mo steroid withdrawal groups were less likely to experience MI (11.1% v. 13.3%, P 〈 0.05), NODM (30.7% to 34.4% v. 37.7%, P 〈 0.05), and cardiac death (29.9% to 30.5% v. 32.4%, P 〈 0.05), compared to steroid maintenance. Conclusions. Strategies of 6- and 12-mo steroid withdrawal post-kidney transplantation are expected to reduce the rates of adverse cardiovascular events and other outcomes with no worsening of AR or GL rates compared with steroid maintenance.
Type of Medium:
Online Resource
ISSN:
0272-989X
,
1552-681X
DOI:
10.1177/0272989X17700879
Language:
English
Publisher:
SAGE Publications
Publication Date:
2017
detail.hit.zdb_id:
2040405-0
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