Modification of Induction in Kidney Transplants with Pre-Transplant Viral Infection or Chronic Long Term Immunosuppression

Purpose:  Standard induction in renal transplant at our center includes Alemtuzumab (C1H) or thymoglobulin (rATG) to facilitate rapid steroid (Sd) withdrawal.  Selected patients with higher infection risk or on long term immunosuppression (LTIS) prior to transplant receive basiliximab (BAS) induction. This was a retrospective review to examine acute cellular rejection (ACR) rate one year post transplant.

Methods:  Adult kidney transplants receive rATG or C1H, followed by tacrolimus (Tac) and mycophenolate (MPA);  BAS Group: Tac, MPA and Sd taper to prednisone 5-10mg/day.  RATG/C1H groups stop Sd on POD 4. Data collected during the first year post transplant and analyzed based on induction therapy.

Results:  BAS induction (n=18) due to pre-transplant viral infection BKV n=1, HCV n=6, CMV n=1, PTLD n=1, long term immunosuppression  n=15 or vasculitis, n=4. One year ACR rate was 50% with severity of Banff I; n=4 and ≥II; n=6. ACR occurred at mean 44.7 and range 8-133 days. ACR occurred in 4 of 10 pts on LTIS and in 5 of 8 pts without LTIS.  Mean Tac levels at 1 month were BAS:9.4+7.4, rATG 8.3+2.1 C1H:7.4+2.4 (p=0.038 BAS vs C1H). In rATG, (n=46) & C1H groups (n=121) ACR was 9% and 11%, occurring at 51 ±62 and 221 ±106 days (p=0.002) respectively with CMV reactivation 5% and 8.6%, BK reactivation 1.5 and 8%. BAS Group CMV reactivation 11% and BK reactivation 16.6%.

Conclusion:  ACR rate of 50% following BAS induction within one year of renal transplant is higher than rATG or C1H. Based on these results, our institution has redesigned patient selection for BAS induction as well as modification to LTIS. Ongoing data collection will be used to assess efficacy/safety of rATG induction with pre-existing viral infection and those chronically immunosuppressed.