Practical Guide on the Use of Induction Immunosuppression in Heart Transplantation

Induction therapy is the use of potent immunosuppression in the perioperative period with the intent to diminish rejection rates in at-risk patients or as a renal-protective strategy. The potent immunomodulatory effects of these agents must be balanced against the recipient's risk of infectious or malignant complications, among others. There is a notable lack of clinically useful risk stratification models that integrate these competing risks and guide the clinician in the use of these therapies. This review integrates the existing evidence on the utility and safety of various induction regimens and highlights the gaps of knowledge in the field. In addition, we frame the discussion in view of the changing landscape of heart transplantation where many unknowns remain, such as the impact of induction immunosuppression on patients bridged with mechanical circulatory devices or receiving organs from hepatitis C-positive or donation after circulatory death donors, among others.