What is your approach to prednisone use in a kidney transplant recipient with allograft failure, residual allograft function, and an ongoing dialysis requirement for more than one year?

It really depends if this patient is a candidate for another transplant, and whether all the other immunosuppression has been weaned off. If they are a candidate for transplant, I am more likely to leave them on prednisone, especially with the residual renal function. If they are not a candidate for re-transplantation my approach is a very slow taper of the prednisone over several months. 5 mg QOD, alternating with 2.5 mg QOD for a month then 2.5 mg QD for a month, then 2.5 mg QOD for a month, and then stop. If they develop signs of rejection of the kidney then I recommend an oral pulse of prednisone at 1 mg kg and then taper.

I prefer to keep patients in this situation on low-dose prednisone indefinitely. Typically a dose of 5-10mg daily.

If there is no prospect of a kidney transplant soon we do not continue on a CNI or anti-metabolite.