Induction therapy by anti-thymocyte globulin (rabbit) versus basiliximab in deceased donor renal transplants and the effect on delayed graft function and outcomes

The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis

BACKGROUND

Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups.

METHODS

We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias.

RESULTS

Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group.

CONCLUSIONS

Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.

The comparative efficacy and safety of basiliximab and antithymocyte globulin in deceased donor kidney transplantation: a multicenter cohort study

BACKGROUND

Generally, an induction agent is chosen based on the conditions of the deceased donor and the recipient. Antithymocyte globulin (ATG) is preferred in relatively high-risk conditions. No clear evidence indicates which induction agent is safer or more efficient for deceased donor kidney transplantation (DDKT). This study compares the efficacy and safety of basiliximab (BSX) and ATG according to donor characteristics in DDKT.

METHODS

A total of 724 kidney transplant recipients from three transplant centers were enrolled, and propensity score matching was performed. Based on a donor age of 60 years, donor kidney with acute kidney injury (AKI), and Kidney Donor Profile Index (KDPI) score of 65%, we investigated how the choice of induction therapy agent affected the posttransplant clinical outcomes of delayed graft function (DGF), acute rejection (AR), infectious complications, and allograft and patient survival.

RESULTS

AR and DGF did not differ significantly according to induction agent in elderly/young donor, AKI/non-AKI, and high-KDPI/ low-KDPI subgroups. The infection rate did not show meaningful differences. The differences in death-censored allograft survival and patient survival rates between induction agents were not statistically significant.

CONCLUSION

Our study suggests that BSX can produce clinical outcomes similarly favorable to those of ATG even in DDKT cases with relatively poor donor conditions. Nonetheless, the donor and recipient conditions, immunological risk, and infection risk must be all taken into consideration when choosing an induction agent. Therefore, clinicians should carefully select the induction therapy agent for DDKT based on the risks and benefits in each DDKT case.

ABO incompatibility in renal transplantation

ABO blood group incompatibility (ABO-I) was historically considered an absolute contraindication to kidney transplantation due to the significant risk of acute antibody-mediated rejection and early graft loss. Nevertheless, the urge to minimize the gap between the candidates’ number on the waitlist for kidney transplants and the available kidney donors encourage investigation into finding ways to use organs from ABO-I kidney donors, especially in the era of using more potent immunosuppression therapies. This review aims to discuss a general overview of ABO-I kidney transplantation and the different protocols adopted by some transplant centers to meaningfully overcome this barrier.

Induction with ATG in DCD kidney transplantation; efficacy and relation of dose and cell markers on delayed graft function and renal function

AIM

We aimed to analyse the efficacy of the Thymoglobulin dose used for induction in controlled DCD kidneys, and its initial impact on blood cell and CD3 count, as predictors of efficacy.

METHODS

140 DCD patients who received ATG induction, were analysed. Intended dose was 1.25 mg/kg/day over 5 days, rounded to nearest 25 mg and not exceeding 125 mg/dose. Outcomes included the total dose in relation with rejection, DGF, graft survival, eGFR. The cell count response to ATG was assessed as predictors of outcome.

RESULTS

Graft survival, was 96.2%, 92.4%, 85% at 1, 3 and 5 years. Rejection was 7% at 1 year and associated with eGFR at 3 (p = 0.003) and 5 years. ATG dose was not predictive of rejection but was associated with the day5 leucocyte and lymphocyte count (p < 0.001) and negatively with DGF (p = 0.05). In 31 patients day3 CD3 count was available and it was associated with rejection (p = 0.002), less DGF (p = 0.09), and 3 years eGFR (p = 0.01).

CONCLUSION

Thymoglobulin provides excellent results in DCD kidneys that do not significantly differ with small dose variations. In higher doses it reduces DGF. Lymphocytes and CD3 count, may be useful surrogate markers of efficacy and outcome.

Impact of Allograft Injury Time of Onset on the Development of Chronic Lung Allograft Dysfunction After Lung Transplantation

The impact of allograft injury time of onset on the risk of chronic lung allograft dysfunction (CLAD) remains unknown. We hypothesized that episodes of late-onset (≥6 months) allograft injury would produce an augmented CXCR3/ligand immune response, leading to increased CLAD. In a retrospective single-center study, 1894 transbronchial biopsy samples from 441 lung transplant recipients were reviewed for the presence of acute rejection (AR), lymphocytic bronchiolitis (LB), diffuse alveolar damage (DAD), and organizing pneumonia (OP). The association between the time of onset of each injury pattern and CLAD was assessed by using multivariable Cox models with time-dependent covariates. Bronchoalveolar lavage (BAL) CXCR3 ligand concentrations were compared between early- and late-onset injury patterns using linear mixed-effects models. Late-onset DAD and OP were strongly associated with CLAD: adjusted hazard ratio 2.8 (95% confidence interval 1.5-5.3) and 2.0 (1.1-3.4), respectively. The early-onset form of these injury patterns did not increase CLAD risk. Late-onset LB and acute rejection (AR) predicted CLAD in univariable models but lost significance after multivariable adjustment for late DAD and OP. AR was the only early-onset injury pattern associated with CLAD development. Elevated BAL CXCR3 ligand concentrations during late-onset allograft injury parallel the increase in CLAD risk and support our hypothesis that late allograft injuries result in a more profound CXCR3/ligand immune response.

Thymoglobulin Induction Therapy in Deceased Donor Kidney Transplantation: Single-Center Experience in Mexico

BACKGROUND

Induction therapy is used to reduce the incidence of graft rejection and delayed graft function. Thymoglobulin is the most used inductor agent in deceased donor kidney transplantation due to its lower rejection and delayed graft function rates.

METHODS

Retrospective study of patients who underwent deceased donor kidney transplantation from 2011 to 2014. Efficacy and safety outcomes evaluated were primary graft nonfunction, delayed graft function, acute rejection episodes, the lowest leukocyte count during the induction, adverse effects, eGFR, and patient and graft survival. P < .05 was considered statistically significant.

RESULTS

A total of 42 patients were registered. Of these, 51.7% were female, with a mean age of 36.4 ± 11.1 years. Mean dialysis time was 112.4 ± 365 months. Mean donor age was 33.7 ± 13.1 years. Of the registered patients, 14.3% were extended criteria donors and 23.8% high-risk. Mean thymoglobulin dose was 4.4 ± 0.8 mg/kg. Primary graft nonfunction was 2.4%. Nineteen percent presented with delayed graft function and 19% with acute rejection. Mean lowest leukocyte count was of 4.6 ± 1.5 × 10(3) cells/mm(3). Mean hospital stay was 11.3 ± 6.3 days. Adverse effects were seen in 59.5% of registered patients, whereas graft survival 1 year and 3 years after transplantation was 85.3% and 56.9%, respectively. Patient survival 1 year and 3 years after transplantation was 85.3% and 53.8%, respectively. Patients who received a higher dose (>4.4 mg/kg) had a shorter hospital stay (9.4 ± 4.6 and 8.1 ± 2.3) than those who received lower dose (13.6 ± 7.9 and 12.8 ± 7.4; P < .05).

CONCLUSION

Thymoglobulin induction at doses near 5 mg/kg in deceased donor kidney transplant is efficient and secure at our center.

Outcome and cost analysis of induction immunosuppression with IL2Mab or ATG in DCD kidney transplants

BACKGROUND

Kidney transplantation from DCD now represents a significant part of the overall transplant activity in the UK. Outcome of different induction immunosuppression regimes and related cost benefit analysis has been reported by very few studies.This is a single centre study on frequency-matched patients who received a DCD kidney transplant between August 2007 and August 2009.

METHODS

Data on 45 patients divided in 2 groups were collected prospectively and analyzed retrospectively. Group A (24 patients) received IL2Mab and Group B (21 patients) ATG as induction immunosuppression. Patient and graft survival were similar in both groups.

RESULTS

In the ATG-induced group, there was a significant lower rate of DGF, BPAR, and infections requiring readmission.A cost analysis was performed including all immunosuppression-related costs, and it has shown remarkable savings in the ATG-induced group.

CONCLUSION

Considering that the number of DCD kidney transplants is destined to rise in the UK, we believe that ATG is a valid option to continue optimizing outcomes of DCD kidney transplant. In our experience, ATG proved to be safe, effective, and contributed to significant cost savings.