Corticosteroids – Azathioprine

Fifteen years ago, classical immunosuppressive therapy was inconceivable without corticosteroids and azathioprine. A large number of transplantees administering these drugs had successful immunosuppression and good function of the graft over longer period of time. Nevertheless, side-effects of corticosteroids to cardiovascular system (hypertension, congestive heart failure, thrombophlebitis), to endocrine system (iatrogenic Cushing’s syndrome, steroid diabetes, hirsutism), osteoarticular system (aseptic necrosis of femoral and humeral head), digestive system and others, contribute to considerable morbidity of these patients. For this reason, the attempts have been made to reduce corticoid doses or even to discontinue their application. Corticosteroid discontinuation leads to decrease of systolic and diastolic blood pressure, and, accordingly, antihypertensive administration may be interrupted in 15% of patients. Likewise, total cholesterol, LDL cholesterol and triglyceride levels, as well as insulin and oral hypoglycemics requirements are diminished. The growth becomes improved in children with transplants administering immunosuppressive therapy without corticosteroids. When decision is made to cease corticosteroid therapy, a good selection of patients is required. The allograft function should be stable (with serum creatinine less than 2.5 mg/dl), while the acute rejection of the graft should not happen within at least 6 months before the decision on corticosteroid discontinuation. Corticosteroids should be discontinued gradually during the period of 3-4 months. Significant is the fact that cadaveric transplantation is used in most countries, and it accounts for 93% of all kidney transplantations in Europe. Data from our country are considerably different: in 1997, out of total number of patients with end-stage CRF, 85% were treated by repeated hemodialysis, 6% by peritoneal dialysis, while only 9% lived with transplanted kidney. On the other hand, out of all transplantations performed up to these days, the graft was received from live donor in even 65% of cases (2), all of them suggesting that this complex medical and organizational problem should be further addressed and solved.