Alemtuzumab [AL] has been increasingly used as an induction agent in renal transplantation. It causes potent lymphocyte depletion and as has been shown to reduce early rejection episodes. Given the sustained reduction in lymphocyte counts, concerns have arisen over the risk of opportunistic infection. The reported dose of AL used in transplantation is highly variable and the optimal dose is not known, although preliminary studies at our centre suggested that the optimal dose to minimise infective and rejection episodes is 0.4mg/kg.

In this study, we report allograft outcomes and microbiological proven infection episodes post dose adjusted AL induction [AD] in patients receiving tacrolimus monotherapy and a steroid sparing protocol compared with a historic control group, who received a 30mg iv standard dose [SD] peri-operatively.

634 and 262 patients received the SD and AD dose respectively. There was no difference in gender, living donor, pre-emptive and ethnic distribution between the 2 groups. However, the AD group were older [52.0±13.1v48.4±13.2yrs, p=0.001], more likely to be receiving a regraft [14.5%v8.0%, p=0.005] and had a higher sensitisation prevalence [38.5%v20.2%, p=0.0001].

Overall patient survival was 87.7% and 94.8%, p=0.69 and graft survival was 79.8% and 96.9%, p=0.07 in the SD and AD groups respectively. Rejection free survival was 74.1% and 78.4% in the SD and AD groups respectively, p=0.63. ACR free survival was 80.1% and 85.3%, p=0.48 and AMR free survival was 92.4% and 92.7%, p=0.95 in the SD and AD groups. DSA free survival was 71.2% and 85.1% in the SD and AD groups, p=0.18. However, infection free survival was inferior in the SD at 48.7% compared with 65.9% on the AD group, p=0.03. On multivariate analysis, factors associated with infection in the AD group were increasing age, p=0.002; female gender, p=0.04 and higher weight at transplant, p=0.0013.

This study shows that dose adjusted AL induction is associated with a reduction of overall infection rates without an increased incidence of rejection.

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