Induction Immunosuppressive Therapy in the Elderly Kidney Transplant Recipient in the United States

Abstract

SummaryBackground and objectives The choice of induction agent in the elderly kidney transplant recipient is unclear. Results In high-risk recipients with high-risk donors there was a higher risk of rejection and functional graft loss with IL2RA versus rATG. Among low-risk recipients with low-risk donors there was no difference in outcomes between IL2RA and rATG. In the two groups in which donor or recipient was high risk, there was a higher risk of rejection but not functional graft loss with IL2RA. Among low-risk recipients with high-risk donors, there was a trend toward a higher risk of death with IL2RA.Conclusions rATG may be preferable in high-risk recipients with high-risk donors and possibly low-risk recipients with high-risk donors. In the remaining groups, although rATG is associated with a lower risk of acute rejection, long-term outcomes do not appear to differ. Prospective comparison of these agents in an elderly cohort is warranted to compare the efficacy and adverse consequences of these agents to refine the use of induction immunosuppressive therapy in the elderly population.

Evaluating Safety and Efficacy of Rabbit Antithymocyte Globulin Induction in Elderly Kidney Transplant Recipients

“…A study by Gill and associates comparing rATG, alemtuzumab, and interleukin-2 receptor antagonists in kidney recipients aged 60 years and older suggests that rATG may be preferable for both low-and high-immunologic-risk recipients (PRA > 20%, prior transplant or black race) who receive high-risk donor kidneys (ECD, DCD, or cold ischemic time > 24 h). 16 In lower risk donor kidneys, patient and graft survival did not differ. In our relatively large retrospective study, we did not find any significant difference in short-term death-censored graft survival, graft function, rejection or safety (infections and rATG tolerability) between elderly and nonelderly kidney recipients who received rATG induction followed by tripleagent, calcineurin inhibitor-based maintenance regimens.…”

“…Many studies have shown that well-selected elderly patients benefit from transplant when compared with those remaining on dialysis, and that patient and graft survival rates are comparable to younger recipients. [1][2][3][4][5]16 Although there is a consensus on the benefit of kidney transplant in the elderly, the optimal immunosuppression strategy for these recipients is not been clearly elucidated. Reduced immune response and a potential for increased risk of infections and malignancies are the main concerns.…”

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“…Induction with r-ATG could be beneficial in these patients based on previous reports. 15,19 In our analysis, 53% of all ECD kidney recipients underwent r-ATG induction, with 73% on chronic steroid maintenance. The results of our study suggest that one has to be cautious in using chronic steroid maintenance in r-ATG-induced ECD kidney recipients especially those over 60 years of age.…”

“…15 With preferential allocation of organs, elderly recipients are more likely to receive ECD kidneys. Based on Scientific Registry of Transplant Recipients data analysis, Schold and associates proposed a model toward efficient use of resources in which older patients can substantially reduce their wait time with receipt of ECD kidneys.…”

“…4,5 Analysis of United Network of Organ Sharing registry by Gill and associates demonstrated a higher risk for acute rejection and trend toward poor allograft survival in elderly kidney transplant recipients who received induction with IL-2B agents compared with r-ATG. 15 The authors recommended the use of r-ATG in elderly patients receiving high-risk donor kidneys including ECD or donation after cardiac death kidneys and kidneys with cold ischemia time > 24 hours. A previous registry analysis reported by our group showed superior patient and graft outcomes with r-ATG induction compared with induction with either alemtuzumab or IL-2B in deceased-donor kidney transplant recipients discharged on a calcineurin inhibitor and mycophenolate mofetil regimen without maintenance steroids.…”