title: Induction by anti-thymocyte globulins in kidney transplantation: a review of the literature and current usage.
abstract: BACKGROUND
  Preventing acute rejection (AR) after kidney transplantation is of utmost importance because an AR can have a negative impact on long-term allograft survival.
  
  
  METHODS
  Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO, and Web of Science have been searched.
  
  
  RESULTS
  At the moment this can be done by using rabbit anti-thymocyte globulins (rATGs) as an induction therapy. However, because rATGs are associated with some deleterious side-effects, such as the opportunistic infections cytomegalovirus (CMV) and de novo post-transplant cancer, it is very important they are used optimally, i.e., at minimal doses that avoid many side-effects but still retain optimal treatment efficacy. Recent data show that the risk of CMV infection can be minimized using tacrolimus plus everolimus, and not tacrolimus plus mycophenolic acid, as the maintenance immunosuppression. The use of rATG is particularly valuable in; (a) sensitized patients; (b) in recipients from an expanded-criteria donor, thus enabling the introduction of calcineurin inhibitors at reduced doses; and (c) for patients where steroid avoidance is contemplated. However, we also need to consider that rATG may increase the risk of de novo cancer, even though recent data indicate this is unlikely and that any risk can be reduced by using mammalian target of rapamycin (mTOR) inhibitors instead of mycophenolic acid combined with low-dose calcineurin inhibitors.
  
  
  CONCLUSIONS
  Even though rATGs do not improve long-term kidney-allograft survival, they may help reduce calcineurin-inhibitor dosage during the early post-transplant period and minimize the risk of AR.
authors.affiliation: Clinique de Néphrologie, University Hospital, Grenoble, France.
authors.forename: Paolo
authors.initials: P
authors.lastname: Malvezzi
authors.affiliation: Clinique de Néphrologie, University Hospital, Grenoble, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: Jouve
authors.affiliation: Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France ; Université Paul Sabatier, Toulouse, France.
authors.forename: Lionel
authors.initials: L
authors.lastname: Rostaing
keywords: Acute rejection; Anti-thymocyte globulins; Cytomegalovirus; De novo cancer; Kidney transplantation