Tailor-Made Induction Therapy in ‘Low Risk’ Renal Transplants; A South Asian Perspective (original) (raw)
Related papers
2018
Kidney transplant is now generally accepted as the treatment of choice for patients with end-stage renal disease. This is because of its association with improved survival and quality of life when compared with other forms of renal replacement therapy. Immunosuppression including induction has played a strong role over the years in improving the outcomes of renal transplant. The main aim of transplant immunosuppression is renal allograft survival in the long term and the patient survival while at the same time reducing the risk of known attendant complications of immunosuppression such as malignancies and infection. The use of induction immunosuppression in low risk kidney transplant recipients varies with different transplant programmes. Different studies in different environments have varying conclusions. While some argue for the use of antibodies as part of induction immunosuppression protocol, the prohibitive cost of these agents preclude their regular use in resource poor envir...
The Influence of Induction Therapy for Kidney Transplantation after a Non-Renal Transplant
Clinical Journal of the American Society of Nephrology, 2011
Summary Background and objectives Non-renal transplant recipients who subsequently develop ESRD and undergo kidney transplantation are medically and immunologically complex due to comorbidities, high cumulative exposure to immunosuppressants, and sensitization to alloantigen from the prior transplant. Although prior non-renal transplant recipients are one of the fastest growing segments of the kidney wait list, minimal data exist to guide the use of antibody induction therapy (IT+) at the time of kidney after lung (KALu), heart (KAH), and liver (KALi) transplant. Design, setting, participants, & measurements This retrospective cohort study used national registry data to examine IT use and survival after kidney transplantation. Separate multivariate Cox regression models were constructed to assess patient survival for IT+ and IT− KALu (n=232), KAH (n=588), and KALi (n=736) recipients. Results Use of IT increased during the study period. The percentage of patients considered highly se...
Transplantation proceedings, 2011
Induction therapies in kidney transplantation have led to prescriptions of lower doses of maintenance immunosuppression and fewer acute rejection episodes. We sought to assess the use of an affordable monoclonal antibody in terms of the incidences of rejection episodes as well as graft and patient survivals and cytomegalovirus (CMV) and opportunistic infections among our kidney transplant recipients between August 2005 and December 2010. Data were obtained for patients who had more than 20 months' follow-up.
Induction Therapy in Renal Transplantation
Drugs, 2007
include progress in the development of new induction protocols (non-depleting versus depleting monoclonal and polyclonal antibodies, plasmapheresis and intravenous immunoglobulins) designed to reduce the incidence and severity of rejection and adverse effects as well as improve long-term graft and patient survival. These modalities have been introduced primarily to reduce the incidence of acute rejection episodes leading to early graft loss, decrease the need for higher toxic doses of maintenance immunosuppressive drugs, such as calcineurin inhibitors, and possibly aid in the pursuit of the goal of achieving immunological tolerance and the avoidance of all long-term immunosuppressive therapy. What has resulted during the past 20 years as the use of induction agents has become more popular is the concurrent improvement in detection and treatment of acute and chronic infectious (primarily viral), and opportunistic and quasi-malignant disease accompanying the use of these agents and, therefore, their increase in popularity. However, the overall cost of therapy and the long-term results of protocols in which these agents have been used have not resulted in a definitive benefit thus far, because of the lack of sufficient numbers of defined randomised, long-term studies and the continuing introduction of newer protocols based on even more recent advances. The specific agents used for induction therapy to date, and the rationale for their introduction and mechanisms of action are discussed in this review.
Impact of Induction Therapy on Clinical Outcomes of Kidney Transplant Recipients
Journal of Renal and Hepatic Disorders
The purpose of this study was to evaluate long-term efficacy of immunosuppressive drugs based on the type of induction therapy given to kidney transplant recipients, and determine the occurrence of graft dysfunctions or rejections. We compared the safety and efficacy of anti-thymocyte globulin (ATG) and basiliximab (BAS) in high-risk patients and analyzed the cumulative incidence of immediate, slow, and delayed graft function in kidney transplant recipients to determine their initial short-term graft function. Evaluation of the long-term efficacy after 3 years post-transplantation by assessment of patients and graft survival, incidence of infections, and risks of rejection were the primary end-points. Patients with stable graft survival were observed more with ATG (85%) than BAS (70%); in contrast, graft dysfunctions, graft nephrec-tomy, rejection episodes, and patient deaths were more prevalent with BAS than ATG, with statistically significant differences in long-term graft functio...
Induction Agent in Low Immunological Risk; the Indian Scenario
Urology & Nephrology Open Access Journal, 2016
Chronic kidney disease (CKD) is a global health problem because of increasing prevalence, high cost of management and risk factor for ischemic heart disease. Renal transplantation remains the current best form of therapy for end stage renal disease (ESRD). Renal transplantation with living kidney donor is better compared to deceased donor transplantation in terms of survival and quality of life. Use of induction agents in renal transplantation has evolved over the years from initial use of muromonab, anti-thymocyte globulins (ATG), and IL-2 blockers to alemtuzumab. Multiple studies have compared these agents in different risk groups and scenarios. There is strong evidence for using ATG compared to IL-2 blockers in high risk group, however, the same does not apply to low risk group. There is a paucity of data regarding the use of induction agents in the Indian subcontinent. The role of induction agents in this population which is prone to opportunistic infections, side effects of drugs and where cost of treatment takes a priority, are not well known especially in low immunological risk group. This review article summarizes the role of various induction agents in different risk groups with relevance to Indian population.
American Journal of Medical Sciences and Medicine, 2019
Objective: This retrospective study discusses the need for induction therapy in half haplotype low immunological risk kidney transplant patients. Material and Methods: Records of 70 adult kidney transplant patients were reviewed with 3 years follow up. All patients were half haplotype matched with their living related donors and had PRA < 20% and DSA 0% when available. We divided the patients into 2 groups based on the induction therapy used during kidney transplantation. Hence, we compared 25 patients who were treated by induction therapy (anti-IL2 receptor antibodies or anti-Thymocyte globulin) (Group I) with 45 other patients who did not get any induction therapy (Group II). The primary endpoints comprised the rate and the severity of acute rejection episodes as well as the 3-year graft function and survival. Secondary endpoints contain: the frequency and the type of infections and the surgical complications at 1 year as well as the amount of malignancy and the patient survival at 1, 6, 12 and 36 months after kidney transplantation. Baseline demographic characteristics including: donor age, recipient and donor gender, cause of kidney disease, dialysis duration, donor to recipient CMV matching were similar in the two groups. Whereas, significant differences existed between the 2 groups in relation to: recipient age, pre-transplant hemoglobin blood level, anti-CMV prophylaxis regimen and maintenance immunosuppression. Results: We did not find any significant difference between the 2 groups regarding the length of hospital stay, the rate and severity of acute rejection, the rate of CMV infection, the occurrence of delayed graft function and the rate and type of surgical complications at 1 year. Furthermore, the patient and graft survival as well as the serum creatinine levels upon discharge and at 1, 3, 6, 12 and 36 months were also comparable. Nevertheless, the rate and type of out of Hospital infections and 1-year infection rate as well as the treatment cost were significantly higher in Group I. Conclusion: Induction therapy might not be desirable in low-immunological risk half-haplotype kidney transplant patients.
PLOS ONE, 2020
Background There is extensive literature with comparisons between Anti-Thymocyte Globulin (ATG) and Basiliximab (BSX) as induction therapy in kidney transplant recipients. The purpose of our benchmarking study was to describe the consequences in terms of practices in 6 transplantation centers of a French prospective cohort. Methods We included adult patients who received a first or second kidney graft between 2013 and 2019 (n = 4157). We used logistic regressions to identify characteristics associated with the use of ATG or BSX. Results Use of ATG between the centers ranged from 41% to 75%. We observed different factors associated with the treatment decision. Compared to a first transplant, performing a second graft was the only factor significantly associated with the choice of ATG in all centers. The AUC ranged from 0.67 to 0.91, indicating that the centers seemed to define their own rules. As a result, for patients with the same low immunological risk, the probability of receiving ATG varied from 7% to 36%. We stratified the analyses according to two periods, from 2013 to 2015 and from 2016 to 2019. A similar heterogeneity was observed, and in some cases ATG indications between the centers were inverted.
Initial Experience with Grafalon as Induction Agent in Kidney Transplantation
JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH
With increasing prevalence of diabetes and hypertension in India, prevalence of Chronic Kidney Disease (CKD) is expected to rise [1]. Population based study from Bhopal estimated average crude and age-adjusted End Stage Renal Disease (ESRD), incidence rates at 151 and 232 per million population respectively [2]. If same incidence rate is extrapolated to rest of the nation, then with current estimated population of 1.326 billion, India will have around 2,00,000-3,00,000 new patients requiring RRT every year. As per Indian CKD registry, of all stage 5 patients, 61% were not on any RRT, 32% were on haemodialysis (HD), 5% were on Peritoneal Dialysis (PD) and <2% were being worked up for transplantation [3]. Renal transplantation is ideal modality of RRT, as it is cost effective and associated with highest quality of life [4]. High cost of immunosuppressive therapy remains the major problem for developing countries like India. Induction immunosuppression is intense immunosuppressive therapy given at the time of transplant to reduce risk of acute rejection [5]. Several studies have shown that graft survival is negatively influenced by acute rejection [6,7]. Apart from reducing acute rejection, another aim of induction therapy is to prolong graft survival. Cost of graft biopsy and treatment of acute rejection are prohibitive for country like India. However, induction agents are also not without harm, as they increase cost of care and are associated with increased risk of infections and posttransplant lymphoproliferative disorders [8]. Hence, cautious use of induction agents at right dose will be most beneficial in terms of cost saving, graft and patient survival. Commonly used induction agents include T-lymphocyte depleting antibody (most commonly rabbit anti-thymocyte globulin-rATG) and IL2 Receptor Antagonist (IL2RA). There is wide variation in use of induction agents. In USA, lymphocyte depleting agents (mainly rATG) are used in majority (61.6%) of renal transplantation and IL2RA being used in 33.3 % patients [9]. In Europe, IL2RA is more widely used than rATG or other depleting agents (12.6% depleting antibody and 25.1% nondepleting antibody) [10]. 'Thymoglobulin' and 'Basiliximab' are the induction agents used for renal transplantation in India [11-14]. There is absence of study with Grafalon as induction agent for renal transplantation from India due to lack of its availability. Present study aimed to evaluate safety and efficacy of Grafalon as induction agent in renal transplantation as it has recently become available in India. MAtERIALS And MEthOdS The present study was a single center prospective study of 11 patients who had received Grafalon © (Neovii Pharmaceuticals AG, Switzerland-formerly known as ATG-Fresenius or ATG-F) as induction agent for renal transplantation between December 2016 to June 2017 at Institute of Kidney Diseases and Research Centre, Ahmedabad, India. Patients included in the study were both living donor and Standard Criteria Deceased (SCD) donor renal transplantation recipients [15]. Written consent was taken from all patients and study was approved by internal review board of institution. All transplants were performed in accordance with declaration of Istanbul [16]. Inclusion criteria in living donor transplantation were ABO compatible recipients with negative Complement-Dependent Cytotoxicity (CDC) cross match, flow cytometric cross match and Donor Specific Antibody (DSA) by luminex. Inclusion criteria in deceased donor DIvyeSh engIneer 1 , hIManShu Patel 2 , vIvek kute 3 , Pankaj Shah 4