*Purpose: The ideal induction therapy for elderly kidney transplant recipients is not known. Given concerns about increased risk of infection and malignancy and perceived decreased risk of rejection centers may favor non-T-cell depleting induction agents in this population. We sought to evaluate our single center experience with elderly recipients after non-T cell depleting induction with basiliximab (BI) versus T-cell depleting induction (TCDI) with either thymoglobulin or alemtuzumab.

*Methods: A retrospective analysis of 1018 kidney transplants performed at our center from 1/3/2013 to 9/4/2018 identified 192 elderly (age > 65 years at transplant) kidney recipients. Six 0-HLA mismatch transplants from this group were excluded from analysis. Outcomes of rejection, allograft loss (total and death censored), and death with a functioning graft were compared between the two induction groups. A subset analysis of recipients aged > 70 years was also performed.

*Results: Of 186 recipients age >65 at time of kidney transplant, 44 (23.6%) received BI. BI was associated with older age (72.0 vs 68.7) vs TCDI. There was a higher proportion of living donors (LD) with BI compared to TCDI (45% vs 27%, p=0.025). BI was associated with increased rates of rejection (30% vs 9%, p=0.002), death censored allograft loss (16% vs 4%, p=0.008), and recipient death (11% vs 7%, p=0.353) compared to TCDI. Mean follow-up was 1001 days in the BI group and 816 days in the TCDI group (p=0.057). Subset analysis for recipients age > 70 again showed a higher proportion of LD with BI. For BI compared to TCDI, acute rejection (25% vs 6%, p=0.041) and death censored allograft loss (16% vs 0%, p<0.001) were more likely though patient deaths were similar (10% vs 9%). Mean follow-up was similar for both arms.

*Conclusions: Elderly kidney transplant recipients may be selected for non-depleting induction therapies based on the perception that they are at increased risk of harm from overimmunosuppression and at a decreased risk of rejection due to immunosenescence. Contrary to this, our center experience shows an unacceptable increased risk of acute cellular rejection and allograft loss with BI in elderly recipients compared to TCDI. The current confidence in older age to protect against rejection is unwarranted and older recipients still benefit from lymphocyte depleting induction.

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