*Purpose: The objective of this retrospective observational study is to compare the safety and efficacy of two dosing strategies, rabbit anti-thymocyte globulin (rATG) at a total cumulative dose of 4.5 mg/kg versus rATG at a total cumulative dose of 6 mg/kg, in high-risk renal transplant patients (re-transplant, panel reactive antibodies > 20%, presence of donor specific antibodies, African Americans < 60 years old, or other ethnicities < 50 years old).

*Methods: A retrospective chart review was conducted in patients who received a renal transplant at CHI Baylor St. Luke’s Medical Center (BSLMC) from January 2019 to September 2020. The following three-month outcomes were analyzed between the two rATG dosing groups: patient survival, graft survival, and incidence of rejection. Secondary outcomes included incidence of thrombocytopenia, leukopenia, infusion related reaction, delayed graft function, and infection.

*Results: A total of 117 patients were included in this study. With regard to patient and graft survival at three months, 100% of the 4.5 mg/kg group (n=46) and 98.6% of the 6 mg/kg group (n=71) survived (P=1). Graft rejection at three months occurred in 6.5% of patients in the 4.5 mg/kg group and 5.6% in the 6 mg/kg group (P =1). Incidence of secondary outcomes in the 4.5 mg/kg and 6 mg/kg group, respectively, were the following: thrombocytopenia (41.3%, 50.7%, P=0.348), leukopenia (41.3%, 45.0%, P=0.707), infusion related reaction (0%, 2.8%, P=0.519), delayed graft function (21.7%, 22.5%, P=1), and infection (60.9%, 56.3%, P=0.703).

*Conclusions: rATG at a total cumulative dose of 4.5 mg/kg is just as effective as 6 mg/kg. There was no significant difference in patient survival, graft survival, or incidence of rejection within three months from transplant. There was also no difference in any of the secondary and safety outcomes analyzed. The lower total dose may result in cost savings.

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