Induction immunosuppression for orthotopic heart transplantation: a review.
OBJECTIVE
To describe the appropriateness and safety of induction immunosuppression for patients at risk for fatal rejection, and to describe the safety and effectiveness profiles of the induction regimens available in the United States.


METHODS
MEDLINE/PubMed database, EMBASE database, Google Scholar; references from pertinent articles were also reviewed to identify additional data.


METHODS
A systematic literature review from January 1, 1980, through June 30, 2008, was performed. Included articles ranged from case series to prospective randomized controlled double-blind placebo-controlled trials that detailed the following topics with respect to induction immunosuppression: risk of fatal rejection, renal sparing, malignancy, OKT3, rabbit or equine antithymocyte globulin, daclizumab, basiliximab, and alemtuzumab.


RESULTS
Patients at highest risk for fatal rejection experienced a survival benefit from induction immunosuppression, whereas all other patients experienced no benefit or harm. Most of the early data detail positive experiences with polyclonal antibody regimens. Several newer trials compare the use of polyclonal strategies with the use of anti-CD25 targeted monoclonal antibodies. Few researchers have assessed the usefulness of an anti-CD52 approach. Overall, induction therapy remains a poorly studied and widely variable practice among the major US heart transplant centers.


CONCLUSIONS
At present, the unrestricted use of induction for all patients does not seem prudent. Induction should be individualized for each patient on the basis of a well-designed protocol, careful analysis of the transplant center's demographics, and the effectiveness and safety profiles of the regimens used.
Ensor
Christopher R
CR
Comprehensive Transplant Center, Johns Hopkins Hospital, 600 North Wolfe St., Carnegie 180, Baltimore, MD 21287, USA. censor1@jhmi.edu
Cahoon
William D
WD
Hess
Michael L
ML
Kasirajan
Vigneshwar
V
Cooke
Richard H
RH
D002985:Clinical Protocols; D006084:Graft Rejection / Q000517:prevention & control; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000494:pharmacology; D012307:Risk Factors; D019172:Transplantation Conditioning / Q000379:methods*
D007166:Immunosuppressive Agents