Alemtuzumab with corticosteroid minimization for pediatric deceased donor renal transplantation: A seven‐yr experience

Abstract

Alemtuzumab is a monoclonal antibody targeting CD52 receptors on B and T lymphocytes and is an effective induction agent in pediatric renal transplantation. We report a seven-yr experience using alemtuzumab induction and steroid-free protocol in the pediatric population as safe and effective. Twenty-one pediatric deceased donor renal transplants were performed at a single academic institution. All received induction with single-dose alemtuzumab and were maintained on a steroid-free protocol using TAC and MMF immunosuppression. There were 15 males and six females in the study whose ages ranged from one to 19 yr. The average follow-up was 32 months (range from 12 to 78.2 months and median 33.7 ± 23.7 months). All patients had immediate graft function. Graft survival was 95%, and patient survival was 100%. Mean 12 and 36 months eGFR were 63.33 ± 21.01 and 59.90 ± 15.27 mL/min/1.73m(2), respectively. Three patients developed acute T-cell-mediated rejection due to non-adherence while no recipients developed cytomegalovirus infection, PTLD, or polyoma BK viral nephropathy. Steroid avoidance with single-dose alemtuzumab induction provides adequate and safe immunosuppression in pediatric deceased donor renal transplant recipients receiving TAC and low-dose MMF maintenance therapy.

No Increased Risk of Posttransplant Lymphoproliferative Disorder Following Alemtuzumab Induction in Kidney Transplant

“…This is similar to other single center studies on alemtuzumab and its impact on PTLD, such as the study from Supe-Markinovina and associates, in which all patients received induction with single-dose alemtuzumab and a steroid-free protocol with tacrolimus and mycophenolate mofetil. 18 Unfortunately, it is impractical to conduct a randomized trial with a control group at a health institution, which often requires a standardized, singular protocol for the treatment of patients.…”

Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient

“…Similar to rATG, alemtuzumab induction is most often used for rejection prophylaxis in high‐risk KTRs and steroid minimization protocols. Standardized dosing for induction in pediatric SOT is not yet established, and further complicated as weight‐based dosing may result in highly variable exposure in children due to nonlinear kinetics with variations in body weight 34 ; suggested dosing recommendations based on single‐arm reports in pediatric kidney transplantation are reported in Table 2 35–41 …”

“…Alemtuzumab induction has been described with positive outcomes in several small pediatric studies in recipients with high immunologic risk and as a strategy for maintenance immunosuppression minimization 33,37,43 . However, the benefits of good allograft outcomes must be seriously evaluated in the context of significant lymphocyte depletion, with reported cell recovery of only 50% from baseline by 12‐months after alemtuzumab induction 35 .…”

Inmunosupresores y principales complicaciones en el trasplante renal pediátrico

“…Según lo informado por Calne y colaboradores (16), se lo ha utilizado como terapia de inducción en trasplante renal en niños desde 1998. Ha mostrado resultados satisfactorios en la terapia de inducción en el trasplante renal pediátrico (3,(17)(18)(19)(20)(21)(22)(23). Estudios de alemtuzumab han revelado beneficios en los pacientes de bajo y alto riesgo inmunológico (24).…”