Steroid Minimization in Kidney Transplantation: Rationale, Implementation, and Future Directions.

Since the 1960s, glucocorticoids have been central to induction and maintenance of immunosuppression in kidney transplantation, but their long-term use is associated with significant toxicity, including post-transplant diabetes mellitus, hypertension, dyslipidemia, osteoporosis, infection, and cardiovascular disease. Advances in immunosuppressive regimens have enabled many transplant centers to reduce or eliminate steroids in selected recipients. Emerging monitoring tools, such as donor-specific antibody surveillance, donor-derived cell-free DNA, and gene-expression profiling, support individualized approaches, particularly in lower-risk patients. This review examines the rationale, evidence, and implementation strategies for steroid minimization and avoidance in kidney transplantation, highlighting current practice patterns, patient selection considerations, ongoing controversies, and future directions toward appropriate use of steroid-sparing regimens as part of personalized immunosuppression.