Do you taper steroids more aggressively to decrease the risk of developing new-onset diabetes after transplantation in kidney transplant recipients who had pretransplant impaired fasting glucose?

Steroids are given after any transplant (kidney, heart, lung, bone marrow, etc.,) to reduce risk of rejection of the transplanted organ. Preservation of organ function is the number one concern for the transplant team. Steroid free regimens for anti-rejection are always a goal but the transition to them should be directed by the primary transplant team not the endocrinologist.

The role of the endocrinologist should be to help effectively manage off target side effects of anti-rejection medications including hyperglycemia and osteoporosis. So, rapid steroid tapers solely to reduce hyperglycemia should not be a key driver of therapeutic changes in transplant medicine. This is similar to not changing immune checkpoint inhibitor therapy in canc...

The Woodle et al., PMID 18936569 randomized controlled trial of early CS withdrawal vs CS maintenance demonstrated no difference in the incidence of pots-transplant diabetes between the two groups. Further data suggest that tacrolimus is a bigger driver of PTDM as compared to steroids especially in the modern era, where in kidney transplant steroids are rapidly tapered to 10 mg/day or less.

Given these findings, we use rapid steroid tapers for all patients down to 10 mg/day or less, regardless of glucose homeostasis status. We couple this with depletional induction.