Selective immunosuppressive therapies based on donor and recipient factors should minimize rejection and optimize patient and graft outcomes. We developed in 2006 a selective algorithm for renal transplant induction therapy choosing between alemtuzumab, basiliximab and anti-thymocyte globulin. We performed 1317 adult renal transplants since initiating this protocol. A retrospective analysis was performed to compare outcomes between patients receiving alemtuzumab (n=613) and those receiving either basiliximab (n=438) or anti-thymocyte globulin (n=352). Patients were analyzed according to receipt of standard criteria (SCD, n=716), expanded criteria (ECD, n=249), or living (n=352) donor renal allografts. Patients receiving alemtuzumab tended to be younger, have a higher BMI, and were less likely to be African-American. There were no significant differences in 1-, 3-, and 5- year graft survival rates when stratified by induction agent in SCD, ECD, or living donor renal transplantation. In SCD recipients undergoing alemtuzumab induction, the rate of rejection at one year was 14%, versus 27% in both patients receiving rATG and receiving basiliximab (p<0.0001). In living-donor renal transplantation, the rate of rejection within the first year in patients receiving alemtuzumab was 10%, versus 17% for rATG, and 29% for basiliximab (p=0.002). No difference in one year rejection rates was noted between the three induction agents in ECD transplantation (alemtuzumab 25%, rATG 30%, basiliximab 32%, p=0.55). There were no differences noted between induction agents related to the incidence of delayed graft function (DGF). In deceased donor recipients, donor age and DGF were risk factors for graft loss. In living donor recipients, an episode of rejection in the first year, DGF, and African-American race proved to be risk factors for graft loss. On multivariate analysis, DGF remained significant as a risk factor for deceased donor allograft loss (HR 2.41, CI 1.75-3.32, P<0.0001) or living donor graft loss (HR 11.08, CI 5.40-20.66, p<0.0001). Patients receiving non-rATG induction had average pharmacy savings of $14,000. Alemtuzumab was associated with lower rejection rates, comparable graft survival, and substantial cost savings in a selective induction protocol. These results provide rationale for more widespread selective application of alemtuzumab induction therapy in renal transplantation.

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