Analysis of rabbit anti‐thymocyte globulin vs basiliximab induction in pediatric liver transplant recipients

Abstract

Literature is limited comparing induction immunosuppression in pediatric liver transplant (LTx) recipients. This is a single‐center, retrospective cohort study of primary pediatric liver transplants at our center between 2005 and 2016 who received either basiliximab (BSX) or rabbit anti‐thymocyte globulin (rATG) induction. Maintenance immunosuppression consisted of tacrolimus ± a corticosteroid taper. Exclusions included receipt of an ABO‐incompatible graft, retransplantation, and multi‐organ transplantation. Primary outcomes were incidence of treated biopsy‐proven acute rejection (tBPAR) and PTLD within the first year and infections within 90 days of LTx. Secondary outcomes included graft and patient survival, time to first tBPAR, and incidence of steroid‐resistant rejection (SRR) within the first year post‐LTx. A total of 136 patients were included in the final analysis of which 57 patients (42%) received BSX induction. Patients who received rATG induction with or without a 2‐week corticosteroid taper experienced significantly more tBPAR compared to those who received BSX induction with a 6‐month corticosteroid taper (55.7% vs 33.3%, P = .01). There were no differences in the incidence of PTLD, infections, SRR, graft or patient survival, or time to first tBPAR between the two groups. Induction with rATG either with or without a short corticosteroid taper was associated with significantly more tBPAR in primary pediatric LTx recipients when compared to BSX induction with a prolonged corticosteroid taper in the setting of maintenance immunosuppression with tacrolimus.

Anti‐thymocyte globulin induction with delayed introduction of tacrolimus preserves renal function in pediatric liver transplant recipients

“…In cost-effective analysis, they found the use of ATG induction resulted in a substantial reduction in drug costs compared to basiliximab. 16 While Newland et al 11 compared ATG to basiliximab induction in children, the primary endpoint was not changes in renal function post liver transplant, and unlike our study, they demonstrated an increase of both rejection and infection when comparing ATG to basiliximab in their cohort.…”

“…10 Pediatric studies on ATG induction for the purpose of preventing CNI-induced renal dysfunction are limited. Newland et al 11 reviewed the use of ATG vs basiliximab induction in a single center fashion. While effects of induction on post-transplant renal function were not evaluated in this study, the ATG group had a paradoxical increase in biopsy proven acute cellular rejection compared to basxiliximab.…”

Variation in immunosuppression practices among pediatric liver transplant centers—Society of Pediatric Liver Transplantation survey results

“…Induction protocols ranged from none to pulse steroids alone to pulse steroids with antibody induction therapy. Limited data exist comparing these strategies head to head, although some studies have suggested increased rejection with the addition of anti‐thymocyte globulin 5,20 . Only four of the responding centers used anti‐A or anti‐B antibody titers to guide therapy in ABO‐incompatible grafts.…”

A network-based approach to identify expression modules underlying rejection in pediatric liver transplantation

“… 7 If this drug is not tolerated, another purine antimetabolite, azathioprine, or a mammalian target of rapamycin (mTOR) inhibitor, rapamycin, can be added to tacrolimus and steroids. Some regimens also include interleukin-2 (IL-2) receptor-blocking or lymphocyte-depleting antibodies from the time of LT. 8 , 9 Time-dependent protocols are used to reduce tacrolimus and steroid doses, based on the likelihood of rejection at various times after Tx. Such reductions can precipitate rejection in some individuals.…”