Induction Therapy in Kidney Transplantation - Summary
Posted Oct 21 2013 12:00am
Most kidney transplant centers in the United States utilize induction agents as part of their immunosupression protocols. The reasoning behind is that induction therapy has been shown to reduce the rate of acute rejection, however no trial has yet demonstrated an improvement in long-term graft survival. Induction therapy has also expanded in centers using steroid-withdrawal protocols and in patients with expected delayed graft function due to prolong ischemia time (ECD/DCD kidneys), since calcineurin inhibitor initiation may be delayed (significant vasoconstriction from CNI may potentially delay recovery).
Rabbit antithymocyte globulin (rATG or Thymoglobulin) is the most common agent used in more than 55% of transplant cases in the USA, despite not being FDA-approved for this use (only for treatment of severe cellular rejection). Curiously, rATG is prepared by immunizing pathogen-free
rabbits with a cell suspension of human thymic tissue (thymocytes). After immunization, the serum is harvested from rabbits and immunoglobulins against thymocytes are isolated and subjected to a number of purification processes. Samples from more than 26,000 immunized rabbits are pooled to achieve a high level of batch-to-batch consistency!
Our center uses ATG for induction in high immunological risk patients and Basiliximab for low risk patients in combination with tacrolimus and MMF for maintenance. Steroid withdrawal is performed on most patients by the end of first week post-transplantation, with the exception of highly sensitized patients.
Below a summary table of the 3 most common induction agents in clinical use today, their target cells, dose, cost and side effects.
AntibodyBrandClassLymphocyte depletingAntigenic Target and CellsTypical prescriptionSide effects
IL2 receptor (CD25)
Activated T cells
20mg x2 doses U$4,254
Hypersensitivity reaction (rare)
Rabbit antithymocyte globulin
Mainly T cells, to a lesser extent B and NK
3-7 doses U$7,824-18,256
Premedicate with steroids and Tylenol
Decrease dose if WBC<3 or="" ptls="" span="">
Fever, chills, dyspnea, nausea, diarrhea,
headache, general pain and pulmonary
edema (cytokine release syndrome)