**10.1 Steroid versus steroid-free protocols**

The known toxicity of long-term steroid exposure has prompted the development of steroidfree immunosuppressive regimens. Benefits of the withdrawal or avoidance of steroids include normal growth in children, improved lipid profiles, improved blood pressure, better glycemic control, and a lower risk of bone disease.

The development of cyclosporine prompted attempts to develop steroid-free protocols. Initially, patients were doing well with cyclosporine monotherapy. Over time, 50% of these patients required steroids, usually for episodes of acute rejection. Strong randomized studies are undoubtedly needed to prove both the efficacy and the safety of these protocols.

Steroid withdrawal has been used as a strategy to avoid adverse steroid effects in transplanted patients. Recent data show that the risk of rejection is higher in patients withdrawn from steroids on a cyclosporine-based protocol. After tacrolimus became available, protocols with this drug showed that withdrawal of steroids after 6 months was successful 80% of the time. More recently, studies involving rapid steroid withdrawal (over 1-2 wk) in patients taking tacrolimus show similar graft survival rates compared with patients withdrawn after 3-6 months. Although the roles of sirolimus and MMF in steroidfree protocols have yet to be definitively determined, the future looks promising for greater use of steroid-free protocols.
