Approach to induction immunosuppressive therapy for HLA- and ABO-compatible kidney transplantation*

* Induction therapy consisting of antibody therapy plus standard immunosuppressive therapy is suggested for most patients undergoing kidney transplantation. However, clinical practice varies worldwide and induction therapy is frequently center specific; at some transplant centers in other countries, induction therapy is not routinely administered.
¶ Recipients of two-haplotype-identical, living, related donor kidneys are at very low risk for acute rejection and, therefore, antibody induction is not indicated. Recipients of a kidney transplant who have another functioning solid organ transplant are typically on long-term maintenance immunosuppression and are at increased risk of infection with lymphocyte depletion.
Δ In patients who are unable to tolerate rATG-Thymoglobulin, such as those who are hypotensive, leukopenic, and/or thrombocytopenic at the time of transplant surgery, basiliximab is an alternative option. Refer to UpToDate content on induction immunosuppressive therapy in kidney transplant recipients for details on dosing and administration.
◊ In patients who are at low immunologic risk of acute rejection, either basiliximab or rATG-Thymoglobulin is a reasonable induction agent. Some experts prefer rATG-Thymoglobulin based upon data showing lower rates of biopsy-proven acute rejection at one year. Other experts prefer basiliximab based upon studies that have shown similar rates of rejection, patient and graft survival, and infection with rATG-Thymoglobulin and basiliximab in low-risk patients. The 2009 KDIGO clinical practice guidelines recommend the use of IL-2 receptor antibodies (ie, basiliximab) as first-line induction therapy in patients not at high immunologic risk. Refer to UpToDate content on induction immunosuppressive therapy in kidney transplant recipients for details on dosing and administration.