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Comparison of infectious complications following early versus late pulse steroid therapy in renal transplant recipients
Shuvam Roy, M R Behera, Anupma Kaul, Narayan Prasad, Dharmendra S Bhadauria, Manas R Patel, Ravi S Kushwaha, Monika Yachha, Priyank Yadav, Hira Lal
Shuvam Roy, M R Behera, Anupma Kaul, Narayan Prasad, Dharmendra S Bhadauria, Manas R Patel, Ravi S Kushwaha, Monika Yachha, Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
Priyank Yadav, Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
Hira Lal, Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
Author contributions: Lal H and Kaul A contributed to conceptualization; Roy S contributed to data collection, ultrasound and shear-wave elastography acquisition, investigation, formal analysis, drafting of the manuscript, data curation; Behera MR contributed to statistical analysis, validation; writing - review and editing, interpretation of results; Kushwaha RS and Kaul A contributed to patient recruitment, clinical evaluation, nephrology inputs, interpretation of biochemical and clinical correlations, manuscript review; Yachha M contributed to patient screening, sample handling, clinical data coordination; Prasad N and Bhadauria DS contributed to clinical supervision, nephrology expertise, guidance on biopsy indications and follow-up interpretation, review of final manuscript; Yadav P contributed to study design support and final approval; Patel MR and Lal H contributed to study design, supervision, methodology, critical revision of the manuscript; Yachha M and Lal H contributed to manuscript editing.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India (IEC code: No. 2023-178-DM-EXP-53).
Informed consent statement: All study participants provided written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement:
There is no additional data available.
Corresponding author: Hira Lal, Professor, Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow 226014, Uttar Pradesh, India.
hiralal2007@yahoo.co.in
Received: December 28, 2025
Revised: January 30, 2026
Accepted: March 2, 2026
Published online: June 25, 2026
Processing time: 169 Days and 16.7 Hours
BACKGROUND
Renal transplant recipients are at increased risk of infections due to immunosuppression. Pulse steroid therapy, used to treat acute rejection, may further heighten this risk. However, the impact of the timing of pulse steroid therapy on infectious complications remains unclear.
AIM
To compare infectious complications following early vs late pulse steroid therapy in renal transplant recipients.
METHODS
This study included adult renal transplant recipients who received pulse steroid therapy either within 90 days (early) or after 90 days (late) post-transplantation between January 2016 and December 2020. Patients receiving both early and late pulse therapy were excluded. Infectious complications requiring hospitalization were recorded from the first pulse steroid dose until death or December 31, 2021. Infection burden was expressed as episodes per 100 patient-years, and incidence rate ratios (IRRs) with 95% confidence intervals (CI) were calculated.
RESULTS
A total of 128 patients were included (early: n = 84; late: n = 44). The overall infection rate was lower in the early group compared with the late group (42.64 episodes per 100 patient-years vs 68.68 episodes per 100 patient-years; IRR = 0.62, 95%CI: 0.46-0.83, P < 0.01). Rates of pneumonia (IRR = 0.44, 95%CI: 0.22-0.86, P = 0.02), sepsis (IRR = 0.35, 95%CI: 0.13-0.96, P = 0.04), and viral infections (IRR = 0.42, 95%CI: 0.19-0.91, P = 0.03) were also lower in the early group. Mortality was significantly higher in patients receiving late pulse steroid therapy (18.2% vs 4.8%, P = 0.02).
CONCLUSION
Late pulse steroid therapy in renal transplant recipients is associated with a significantly higher burden of infectious complications and mortality compared with early therapy. These findings highlight the need for enhanced surveillance and tailored infection prevention strategies following late intensification of immunosuppression.
Core Tip: The infectious risk associated with pulse steroid therapy in renal transplant recipients may depend on its timing after transplantation. In this study, patients receiving late pulse steroid therapy (after 90 days post-transplant) experienced significantly higher rates of overall infections, pneumonia, sepsis, and viral infections compared with those treated early. These findings suggest that late intensification of immunosuppression carries a greater infectious burden and highlight the need for enhanced surveillance and reconsideration of prophylactic strategies when pulse steroids are administered in the late post-transplant period.
