Outcomes Associated with Steroid Avoidance and Alemtuzumab among Kidney Transplant Recipients.
OBJECTIVE
Alemtuzumab is a humanized anti-CD52 monoclonal antibody used as induction in kidney transplantation (KTX) since 2003. Few studies have evaluated long-term outcomes of this agent or changes in outcomes over time.


METHODS
A retrospective cohort study was performed examining United States registry data from 2003 to 2014 of primary KTX recipients receiving induction with alemtuzumab (AZ; n=5521) or antithymocyte globulin (ATG; n=8504) and maintenance immunosuppression with tacrolimus and mycophenolate mofetil and early withdrawal of steroids. The primary outcome was overall death-censored graft survival (DCGS), and secondary outcomes were overall patient survival and 1-year acute rejection. Multivariate models were fit with donor, recipient, and transplant covariates. Because poorer outcomes with AZ may occur from a learning curve impact with the use of a new medication, transplant year was categorized into three time periods to evaluate outcomes over time (2003-2005, 2006-2008, ≥2009), and an interaction term of induction type with transplant year category was included in all models to test for era impacts.


RESULTS
On multivariate analysis of DCGS there was a significant interaction between AZ and era (P<0.001). AZ was significantly associated with inferior DCGS in the earliest 2003-2005 era (adjusted hazard ratio [aHR], 2.21; 95% confidence interval [95% CI], 1.72 to 2.84) but not in the middle 2006-2008 era (aHR, 1.14; 95% CI, 0.96 to 1.36) or the most recent 2009-2014 era (aHR, 1.08; 95% CI, 0.90 to 1.29) compared with ATG. Risk-adjusted patient survival (aHR, 1.32; 95% CI, 1.08 to 1.61; aHR, 1.26; 95% CI, 1.09 to 1.46; and aHR, 1.10; 95% CI, 0.93 to 1.29 by era, respectively) and acute rejection (adjusted odds ratio [aOR], 1.17; 95% CI, 0.96 to 1.42; aOR, 0.94; 95% CI, 0.82 to 1.07; aOR, 0.89; 95% CI, 0.81 to 0.98 by era, respectively) with AZ was comparable with ATG in the most recent era; however, there was no significant interaction with time (P=0.13 and P=0.06, respectively).


CONCLUSIONS
Current alemtuzumab utilization is associated with comparable graft and patient survival and acute rejection compared with ATG. Graft survival with alemtuzumab has improved over time.
Department of Surgery, Montefiore Medical Center, Bronx, New York; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York;
Oscar K
OK
Serrano
Department of Medicine, Albert Einstein College of Medicine, Bronx, New York;
Patricia
P
Friedmann
Department of Surgery, Case Western Reserve, Cleveland, Ohio; and.
Sayeeda
S
Ahsanuddin
Department of Surgery, Montefiore Medical Center, Bronx, New York; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York;
Carlos
C
Millan
Department of Surgery, Rabin Medical Center, Petah Tikva, Israel.
Almog
A
Ben-Yaacov
Department of Surgery, Montefiore Medical Center, Bronx, New York; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York; liisekayler@yahoo.com.
Liise K
LK
Kayler
D000293:Adolescent; D000305:Adrenal Cortex Hormones; D000328:Adult; D000074323:Alemtuzumab; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D002648:Child; D015331:Cohort Studies; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
D000305:Adrenal Cortex Hormones; D061067:Antibodies, Monoclonal, Humanized; D000074323:Alemtuzumab
acute allograft rejection; chronic graft deterioration; renal transplantation