Is induction therapy still needed in heart transplantation?

Induction therapy has continued to be a subject of controversy in heart transplantation for more than 20 years. The benefits and safety of this approach as a universal strategy have been studied during the past decade with disparate results. This report reviews the challenges in induction therapy during the past decade, describes the recent reports, and explores the pitfalls and benefits of using this strategy in heart transplantation.

Recent developments in induction therapy have paved the way for new approaches how to use antibodies in this setting. Alemtuzumab, a new monoclonal antibody against the CD52 antigen on mature lymphocytes, was successfully tested in cardiac transplant patients, showing significantly less rejection incidence with low infection rates. Long-term examinations of antithymocyte globulin induction showed lower rejection rates and no increase of posttransplantation lymphoproliferative disease risk. However, higher infection rates were found. Patient groups have been selected who might have particular benefit form induction therapy. These groups consist of patients with a high risk to develop cellular or antibody rejection, patients with impaired renal function in who introduction of calcineurin inhibitor therapy should be delayed and patients with calcineurin inhibitor-free therapy.

Induction therapy still has its place in the immunosuppressive armamentarium after cardiac transplantation. New antibody generations and the selection of special patient groups demonstrate that induction therapy is effective and well tolerated in its use.