Lack of Benefit and Potential Harm of Induction Therapy in Simultaneous Liver‐Kidney Transplants

Abstract

United States for 2002-2016. The cohort was divided into 3 groups on the basis of induction type: rabbit antithymocyte globulin (r-ATG; n = 831), interleukin 2 receptor antagonist (IL2RA; n = 1558), and no induction (n = 2333). Primary outcomes were posttransplant all-cause mortality and acute rejection rates in kidney and liver allografts at 12 months. Survival rates were analyzed by the Kaplan-Meier method. A propensity score analysis was used to control potential selection bias. Multivariate inverse probability weighted Cox proportional hazard and logistic regression models were used to estimate the hazard ratios (HRs) and odds ratios. Among SLKT recipients, survival estimates at 3 years were lower for recipients receiving r-ATG (P = 0.05). Compared with no induction, the multivariate analyses showed an increased mortality risk with r-ATG (HR, 1.29; 95% confidence interval [CI], 1.10-1.52; P = 0.002) and no difference in acute liver or kidney rejection rates at 12 months across all induction categories. No difference in outcomes was noted with IL2RA induction over the no induction category. In conclusion, there appears to be no survival benefit nor reduction in rejection rates for SLKT recipients who receive induction therapy, and r-ATG appears to increase mortality risk compared with no induction.

Lack of Benefit and Potential Harm of Induction Therapy in Simultaneous Liver‐Kidney Transplants

“…We are surprised by these results mainly for 2 reasons: Our program recently published a series of CLKTs where r‐ATG induction was used in all recipients with excellent outcomes Our program also contributed ~18% (146/831 CLKTs) of the r‐ATG induction group mentioned previously …”

“…B). It is also interesting to note that AbdulRahim et al reported no difference in the causes of death between the 3 groups . Therefore, it is unclear where the true negative impact of r‐ATG induction lies if the cause of death is not infectious or cardiovascular in nature, which would be expected if this were the case.…”

“…We read with great interest the article by AbdulRahim et al, which studied the impact of induction therapy on patient survival following combined liver‐kidney transplantation (CLKT). The article included national data from 2002 to 2016 analyzing 4722 CLKTs: No induction (n = 2333). Interleukin 2 receptor antagonist induction (n = 1558). Rabbit antithymocyte globulin (r‐ATG) induction (n = 831). …”

“…The authors performed a detailed statistical analysis including several donor and recipient variables. They concluded that r‐ATG induction is potentially harmful and increases mortality risk compared with no induction in CLKT (hazard ratio, 1.29; 95% confidence interval, 1.10‐1.52; P = 0.002) …”

Reply

“…Our group recently published Organ Procurement and Transplantation Network registry data comparing outcomes among induction agents in simultaneous liver‐kidney transplantations (SLKTs) in the context of contemporary maintenance immunosuppression of tacrolimus (TAC)/mycophenolic acid (MPA). We primarily looked at posttransplant all‐cause mortality and acute rejection rates in kidney and liver allografts at 12 months in SLKT . We thank Ekser et al for sharing their experience with thymoglobulin as an induction therapy in their population of SLKT patients.…”