*Purpose: Alemtuzumab and rabbit anti-thymocyte globulin (rATG) are commonly used lymphocyte depleting induction agents. Traditional thinking suggests that re-transplantation is associated with higher rejection risk, due to the sensitizing effect of the primary transplant and lymphocyte depletion is required. However, it is unknown which induction agent is preferred in the setting of non-primary transplant, particularly when alemtuzumab was used as the primary transplant induction.

*Methods: This was a single center, retrospective cohort study of adult patients who underwent kidney or pancreas transplantations at our institution between 1/1/2001 – 12/31/2016. Patients were included if they received a primary transplant with alemtuzumab induction followed by a secondary kidney or pancreas transplant with alemtuzumab (a/a) or rATG (a/r) induction. Patients were excluded if their transplant combination was not primary/secondary. The purpose of this study was to evaluate safety and efficacy of secondary transplant with alemtuzumab vs rATG induction after primary transplant with alemtuzumab induction.

*Results: A total of 45 patients met study inclusion criteria; 16 patients in the a/a group and 29 in the a/r group. Patient demographics were similar between groups; the majority of patients received kidney transplants. The a/a group had significantly fewer days between transplant 1 and 2 (621 ± 821.8 vs 2024.4 ± 1285.8, p=0.049) and lower peak cPRA prior to transplant 2 (15.7±31.5 vs 53.2±37.8; p=0.0003). The a/a group experienced increased fungal infections at year 1 (18.7% vs 11.3%) and year 5 (46.8% vs 11.3%, p=0.02) vs a/r. This finding persisted in a multivariable model adjusting for transplant type (CI 0.95 – 16.5, p=0.0587). The a/a group experienced an elevated rate of bacterial infection at 5 years (78.5% vs 47.5%, p=0.19). Incidence of rejection was not different between groups at 1 year (a/a 25% vs a/r 24.2%) but 5 year rejection rates trended to increased rejection in the a/a group despite lower pretransplant cPRA (50% vs 24.2%, p=0.27). Rates of CMV, BK, patient and graft survival were similar (p=0.73, p=0.72, p=0.48 and p=0.87 respectively).

*Conclusions: The findings of our study suggest that patients with multiple courses of alemtuzumab induction have a higher incidence of fungal infection, however this does not appear to be associated with reduction of graft or patient survival. Future studies are needed to better elucidate the etiology of this association and stratify risk to better select the best induction agent at the time of non-primary transplant.

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