Rabbit Antithymocyte Globulin vs Basiliximab Induction in ABO-Incompatible Kidney Transplantation: A Single-Center...

Rabbit antithymocyte globulin (rATG) is frequently used in immunologically high-risk kidney transplantation (KT), but its comparative effectiveness and safety vs basiliximab in ABO-incompatible (ABOi) KT are not well established. We aimed to compare outcomes of rATG and basiliximab induction in ABOi KT and to evaluate whether ABO compatibility modifies these associations.

We conducted a retrospective single-center cohort study of adult KT recipients at Seoul St. Mary's Hospital between 2011 and 2020. Patients receiving rATG or basiliximab induction were identified and stratified by ABO compatibility. Primary outcomes were overall patient survival, death-censored graft survival (DCGS), and rejection-free graft survival. Secondary outcomes included serious infection requiring hospitalization and post-transplant malignancy. Time-to-event analyses were performed using Kaplan-Meier methods and Cox proportional hazards models, with an interaction term between induction agent and ABO incompatibility.

Among 1546 KT recipients, 285 underwent ABOi KT, including 69 receiving rATG and 216 basiliximab. In unstratified analyses, overall patient survival, rejection-free graft survival, and infection-related hospitalization did not differ significantly between induction strategies. Cytomegalovirus viremia was more frequent in the rATG group. In adjusted models, a significant interaction between induction strategy and ABO compatibility was observed for DCGS (P = .031), whereas no significant interactions were observed for rejection-free graft survival or overall patient survival.

In ABOi KT, rATG induction was associated with improved DCGS compared with basiliximab, while patient survival and serious infectious complications were similar. The association between induction strategy and graft survival varied by ABO compatibility, supporting a risk-adapted approach to induction therapy.