Editorial
Copyright ©2012 Baishideng. All rights reserved.
World J Transplant. Apr 24, 2012; 2(2): 19-26
Published online Apr 24, 2012. doi: 10.5500/wjt.v2.i2.19
Antibody induction therapy in adult kidney transplantation: A controversy continues
Kanwaljit K Chouhan, Rubin Zhang
Kanwaljit K Chouhan, Rubin Zhang, Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, United States
Author contributions: Chouhan KK contributed to the design of the paper, acquisition, analysis and interpretation of the data from various studies which are reviewed in this paper, she also contributed to the final approval of the version to be published; Zhang R contributed by drafting the paper and revised it critically for important intellectual content, he also contributed to the final approval of the version to be published.
Correspondence to: Rubin Zhang, MD, FASN, Professor of Medicine, Medical Director of Kidney and Pancreas Transplantation, Tulane University Abdominal Transplant Institute, 1415 Tulane Ave, TW-35, New Orleans, LA 70112, United States. rzhang@tulane.edu
Telephone: +1-504-9881457 Fax: +1-504-9881105
Received: June 24, 2011
Revised: March 14, 2012
Accepted: March 20, 2012
Published online: April 24, 2012
Abstract

Antibody induction therapy is frequently used as an adjunct to the maintenance immunosuppression in adult kidney transplant recipients. Published data support antibody induction in patients with immunologic risk to reduce the incidence of acute rejection (AR) and graft loss from rejection. However, the choice of antibody remains controversial as the clinical studies were carried out on patients of different immunologic risk and in the context of varying maintenance regimens. Antibody selection should be guided by a comprehensive assessment of immunologic risk, patient comorbidities, financial burden as well as the maintenance immunosuppressives. Lymphocyte-depleting antibody (thymoglobulin, ATGAM or alemtuzumab) is usually recommended for those with high risk of rejection, although it increases the risk of infection and malignancy. For low risk patients, interleukin-2 receptor antibody (basiliximab or daclizumab) reduces the incidence of AR without much adverse effects, making its balance favorable in most patients. It should also be used in the high risk patients with other medical comorbidities that preclude usage of lymphocyte-depleting antibody safely. There are many patients with very low risk, who may be induced with intravenous steroids without any antibody, as long as combined potent immunosuppressives are kept as maintenance. In these patients, benefits with antibody induction may be too small to outweigh its adverse effects and financial cost. Rituximab can be used in desensitization protocols for ABO and/or HLA incompatible transplants. There are emerging data suggesting that alemtuzumab induction be more successful than other antibody for promoting less intensive maintenance protocols, such as steroid withdrawal, tacrolimus monotherapy or lower doses of tacrolimus and mycophenolic acid. However, the long-term efficacy and safety of these unconventional strategies remains unknown.

Keywords: Induction, Kidney transplant, Thymoglobulin, Basiliximab, Alemtuzumab, Acute rejection, Graft survival