Early steroid withdrawal in HIV-infected kidney transplant recipients: Utilization and outcomes.

Kidney transplant (KT) outcomes for HIV-infected (HIV+) persons are excellent, yet acute rejection (AR) is common and optimal immunosuppressive regimens remain unclear. Early steroid withdrawal (ESW) is associated with acute rejection (AR) in other populations, but its utilization and impact are unknown in HIV+ KT. Using SRTR, we identified 1225 HIV+ KT recipients between 1/1/2000-12/31/2017 without AR, graft failure, or mortality during KT admission, and compared those with ESW versus steroid continuation (SC). We quantified associations between ESW and AR using multivariable logistic regression and interval-censored survival analysis, as well as with graft failure and mortality using Cox regression, adjusting for donor, recipient, and immunologic factors. ESW utilization was 20.4%, with more zero HLA mismatch (8% vs 4%), living donors (26% vs 20%), and lymphodepleting induction (64% vs 46%) compared to the SC group. ESW utilization varied widely across 129 centers, with less use at high versus moderate volume centers (6% vs 21%, p<0.001). AR was more common with ESW by one year (18.4% vs 12.3%; aOR:1.08 1.612.41 , p=0.04) and over the study period (aHR:1.02 1.391.90 , p=0.03), without difference in death-censored graft failure (aHR 0.60 0.911.36 , p=0.33) or mortality (aHR:0.75 1.151.77 , p=0.45). To reduce AR after HIV+ KT, tailoring of ESW utilization is reasonable.