title: Acute Rejection Rates and Graft Outcomes According to Induction Regimen among Recipients of Kidneys from Deceased Donors Treated with Tacrolimus and Mycophenolate.
abstract: IL-2 receptor antagonist (IL2-RA) is recommended as a first-line agent for induction therapy in renal transplantation. However, this remains controversial in deceased donor renal transplantation (DDRT) maintained on tacrolimus (TAC)/mycophenolic acid (MPA) with or without steroids.
  
  
  
  We studied the United Network for Organ Sharing Registry for patients receiving DDRT from 2000 to 2012 maintained on TAC/MPA at transplantation hospital discharge (n=74,627) to compare outcomes of IL2-RA and other induction agents. We initially divided the cohort into two groups on the basis of steroid use at the time of discharge: steroid (n=59,010) versus no steroid (n=15,617). Each group was stratified into induction categories: IL2-RA, rabbit antithymocyte globulin (r-ATG), alemtuzumab, and no induction. The main outcomes were incidence of acute rejection within the first year and overall graft failure (defined as graft failure and/or death) post-transplantation. Propensity score (PS), specifically inverse probability of treatment weight, analysis was used to minimize selection bias caused by nonrandom assignment of induction therapies.
  
  
  
  Median (25th, 75th percentiles) follow-up times were 3.9 (1.1, 5.9) and 3.2 (1.1, 4.9) years for steroid and no steroid groups, respectively. Acute rejection within the first year and overall graft failure within 5 years of transplantation were more common in the no induction category (13.3%; P<0.001 and 28%; P=0.01, respectively) in the steroid group and the IL2-RA category (11.1%; P=0.16 and 27.4%; P<0.001, respectively) in the no steroid group. Compared with IL2-RA, PS-weighted and covariate-adjusted multivariable logistic and Cox analyses showed that outcomes in the steroid group were similar among induction categories, except that acute rejection was significantly lower with r-ATG (odds ratio [OR], 0.68; 95% confidence interval [95% CI], 0.62 to 0.74). In the no steroid group, compared with IL2-RA, odds of acute rejection with r-ATG (OR, 0.80; 95% CI, 0.60 to 1.00) and alemtuzumab (OR, 0.68; 95% CI, 0.53 to 0.88) were lower, and r-ATG was associated with better graft survival (hazard ratio, 0.86; 95% CI, 0.75 to 0.99).
  
  
  
  In DDRT, compared with IL2-RA induction, no induction was associated with similar outcomes when TAC/MPA/steroids were used. r-ATG seems to offer better graft survival over IL2-RA in steroid avoidance protocols.
authors.affiliation: Division of Nephrology and.
authors.forename: Bekir
authors.initials: B
authors.lastname: Tanriover
authors.affiliation: Division of Nephrology and.
authors.forename: Vishal
authors.initials: V
authors.lastname: Jaikaransingh
authors.affiliation: Departments of Surgery and.
authors.forename: Malcolm P
authors.initials: MP
authors.lastname: MacConmara
authors.affiliation: Departments of Surgery and.
authors.forename: Justin R
authors.initials: JR
authors.lastname: Parekh
authors.affiliation: Division of Nephrology and.
authors.forename: Swee-Ling
authors.initials: SL
authors.lastname: Levea
authors.affiliation: Division of Nephrology and.
authors.forename: Venkatesh K
authors.initials: VK
authors.lastname: Ariyamuthu
authors.affiliation: Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Song
authors.initials: S
authors.lastname: Zhang
authors.affiliation: Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Ang
authors.initials: A
authors.lastname: Gao
authors.affiliation: Information Systems, Naveen Jindal School of Management, University of Texas at Dallas, Dallas, Texas.
authors.forename: Mehmet U S
authors.initials: MUS
authors.lastname: Ayvaci
authors.affiliation: Booth School of Business, University of Chicago, Chicago, Illinois.
authors.forename: Burhaneddin
authors.initials: B
authors.lastname: Sandikci
authors.affiliation: Division of Nephrology and.
authors.forename: Nilum
authors.initials: N
authors.lastname: Rajora
authors.affiliation: Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas; and.
authors.forename: Vaqar
authors.initials: V
authors.lastname: Ahmed
authors.affiliation: Division of Nephrology and.
authors.forename: Christopher Y
authors.initials: CY
authors.lastname: Lu
authors.affiliation: Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Sumit
authors.initials: S
authors.lastname: Mohan
authors.affiliation: Division of Nephrology and.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Vazquez
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000074323:Alemtuzumab / Q000627:therapeutic use*; D000961:Antilymphocyte Serum / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology* / Q000517:prevention & control; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D060828:Induction Chemotherapy / Q000379:methods*; D016030:Kidney Transplantation / Q000379:methods*; D060046:Maintenance Chemotherapy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000627:therapeutic use; D057216:Propensity Score; D015375:Receptors, Interleukin-2 / Q000037:antagonists & inhibitors; D012042:Registries; D013256:Steroids / Q000627:therapeutic use*; D016559:Tacrolimus / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D015375:Receptors, Interleukin-2; D013256:Steroids; D000074323:Alemtuzumab; D009173:Mycophenolic Acid; D016559:Tacrolimus
keywords: Antibodies, Monoclonal, Humanized; Antilymphocyte Serum; Follow-Up Studies; Graft Survival; Humans; Immunosuppression; Immunosuppressive Agents; Mycophenolic Acid; Tissue Donors; kidney transplantation; rejection; tacrolimus