Impact of induction agent selection on rejection, allograft function, and survival in kidney transplant recipients

Kidney allograft rejection, driven by the recipient's immune response to non-self-HLA, remains a key barrier to kidney allograft survival. Induction therapy seeks to suppress early alloimmunity and reduce rejection. This study compares Basiliximab, Alemtuzumab, and Thymoglobulin in terms of acute rejection, kidney allograft function, and patients' survival.

A retrospective, single-center cohort study was conducted on 917 kidney transplant recipients between January 2019 and December 2023. Patients were stratified into Alemtuzumab (n = 337), Basiliximab (n = 300), and Thymoglobulin (n = 280) groups. The primary outcome was biopsy-proven acute rejection within the first 12 months post-transplant. Secondary outcomes included kidney allograft function. Kaplan-Meier survival analysis was performed to assess survival differences across groups.

There was no statistically significant difference in acute rejection rates within the first 12 months among the three induction groups: Basiliximab (15 %), Thymoglobulin (14 %), and Alemtuzumab (9 %) (p = 0.16). Median creatinine clearance showed significant differences, with higher values in the Thymoglobulin (57.0 mL/min) and Alemtuzumab (56.0 mL/min) groups compared to the Basiliximab group (48.0 mL/min) (p = 0.003). Kaplan-Meier survival analysis demonstrated a statistically significant difference in patient survival over the 5-years follow-up period, with the highest survival observed in the Alemtuzumab group, followed by Thymoglobulin and then Basiliximab (p = 0.0067).

Basiliximab showed similar acute rejection rates to lymphocyte-depleting agents, suggesting it is not inferior in preventing early rejection when used for a selected group of patients. These findings support the need for further multi-center studies to better define optimal induction strategies and adapt therapy to individual patient profiles.