*Purpose: The optimal dose of anti-thymocyte globulin (ATG) as an induction regimen in Asian kidney recipients is unclear.

*Methods: Using Korean Organ Transplantation Registry database, we performed a retrospective cohort study of 4579 adult patients who received renal transplantation in South Korea between January, 2015 and December, 2019. Patients who received ATG induction were divided into two groups according to the dose of ATG. Clinical outcomes were compared among basiliximab, low- and high-dose ATG induction groups. For creating high-quality propensity score weights, The Toolkit for Weighting and Analysis of Nonequivalent Groups (TWANG) package was applied.

*Results: Of the 924 recipients with ATG induction, 467 were classified as low-dose ATG group and 457 as high-dose ATG group based on median value of ATG dose, 4.5mg/kg. During the four-year follow-up, the rate of biopsy-proven acute rejection was significantly higher in the high-dose group compared with other groups (high-dose ATG 25.6%, low-dose ATG 22.4%, and basiliximab 20.8%, p <0.0001). However, overall graft failure was significantly lower in the high-dose ATG group (high-dose ATG 2.6%, low-dose ATG 5.0%, and basiliximab 4.0%, p <0.0001) whereas there was no significant difference in death-censored graft failure between groups (high-dose ATG 1.7%, low-dose ATG 2.2%, and basiliximab 2.4%, p =0.08). Furthermore, mortality was significantly lower in the high-dose ATG group (high-dose ATG 1.0%, low-dose ATG 2.8%, and basiliximab 1.7%, p <0.0001). There was no significant difference in the level of serum creatinine between groups.

*Conclusions: Compared to basiliximab and low-dose ATG induction, high-dose ATG induction (more than 4.5mg/kg) showed superior outcomes in terms of overall graft survival and patient survival.

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