Increased risk of rejection after basiliximab induction in sensitized kidney transplant recipients without pre‐existing donor‐specific antibodies – a retrospective study

Abstract

Depleting induction therapy is recommended in sensitized kidney transplant recipients (KTRs), though the detrimental effect of nondonor-specific anti-HLA antibodies is not undeniable. We compared the efficacy and safety of basiliximab and rabbit anti-thymocyte globulin (rATG) in sensitized KTRs without pre-existing donor-specific antibodies (DSAs). This monocentric retrospective study involved all sensitized KTR adults without pre-existing DSAs (n = 218) who underwent transplantation after June 2007. Patients with basiliximab and rATG therapy were compared for risk of biopsy-proven acute rejection (BPAR) and a composite endpoint (BPAR, graft loss and death) by univariate and multivariate analysis. Patients with basiliximab (n = 60) had lower mean calculated panel reactive antibody than those with rATG (n = 158; 23.7 AE 24.2 vs. 63.8 AE 32.3, P < 0.0001) and more often received a first graft (88% vs. 54%, P < 0.0001) and a transplant from a living donor (13% vs. 2%, P = 0.002). Risks of BPAR and of reaching the composite endpoint were greater with basiliximab than rATG [HR = 3.63 (1.70-7.77), P = 0.0009 and HR = 1.60 (0.99-2.59), P = 0.050, respectively]. Several adjustments did not change those risks [BPAR: 3.36 (1.23-9.16), P = 0.018; composite endpoint: 1.83 (0.99-3.39), P = 0.053]. Infections and malignancies were similar in both groups. rATG remains the first-line treatment in sensitized KTR, even in the absence of pre-existing DSAs.

A Randomized Prospective Study Comparing Anti–T-Lymphocyte Igs to Basiliximab in Highly Sensitized Kidney Transplant Patients

“…Surprisingly, the incidence of de novo DSA was high in their study: 15.8% in patients receiving rATG and 21.7% in patients receiving basiliximab. 6 The difference between our results and the Goumard et al 6 study may be explained by differences in the immunosuppression maintenance protocols as well as the levels and doses of immunosuppressants used in the 2 studies. The high incidences of acute rejection and de novo DSA in the Goumard et al 6 study can be related to a low maintenance immunosuppression.…”

“…Interestingly, the 5year follow-up of patients enrolled in the TAXI study indicates that despite the higher incidence of acute rejection in the daclizumab treatment arm, there was no significant difference in graft survival at the 5-year time point between the 2 treatment arms. 10 Goumard et al 6 reported a similar 4-year survival with induction therapies. In our study, patient survival and graft survival did not differ between the 2 treatment arms.…”

“…In a recent retrospective study that compared rATG with basiliximab in sensitized kidney-transplant patients without pDSAs, Goumard et al 6 found that the composite endpoint, including confirmed acute rejection, graft loss, and death, occurred more frequently in patients receiving basiliximab. In the present study, treatment failure defined by BPAR, patient lost to follow-up, graft loss, and death at 6 or at 12 months did not differ between the 2 groups.…”

“…More recently, in a retrospective study, Goumard et al. 6 reported a significantly higher incidence of acute rejection in anti-HLA–sensitized kidney-transplant patients without preformed DSAs given basiliximab when compared with patients given rATG. However, characteristics between the 2 groups differed significantly, specifically in relation to variables that can influence the acute rejection rate, such as the number of HLA mismatches and calculated PRA rates.…”

Utility or futility of Interleukin 2 receptor antagonist ( IL 2 RA ) induction in kidney transplants‐ the devil is in the detail

“…In this background comes the study from Goumard et al [14] published in this issue. The study tries to assess patients at intermediate risk (sensitized patients with anti-HLA antibodies but no donor specific antibodies DSA) and assess if IL2RA compared to ATG might provide similar efficacy (rejection and graft survival) and better safety (infection and malignancy).…”