INDUCTION IN LOW IMMUNOLOGICAL RISK RENAL TRANSPLANT RECIPIENTS: EMERGING EVIDENCE AGAINST KDIGO TRANSPLANT RECIPIENT GUIDELINES

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Abstract Title *

INDUCTION IN LOW IMMUNOLOGICAL RISK RENAL TRANSPLANT RECIPIENTS: EMERGING EVIDENCE AGAINST KDIGO TRANSPLANT RECIPIENT GUIDELINES

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Co-author 1

Sanjiv Mahajan drsanjivmahajan@yahoo.com VMMC & Safdarjung Hospital Nephrology & Renal Transplant Medicine New Delhi India *

Co-author 2

Rajesh Kumar drrajeshkumar80@yahoo.com VMMC & Safdarjung hospital Nephrology & Renal Transplant Medicine New Delhi India -

Co-author 3

Adarsh Kumar adarshnephro081@gmail.com VMMC & Safdarjung Hospital Nephrology & Renal Transplant Medicine New Delhi India -

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Introduction

KDIGO Transplant Recipient Guidelines (2009) recommend that an interleukin-2 receptor antagonist (IL2-RA) be the first line induction therapy in all renal transplant recipients except in high immunological risk (Rating 1B). An IL2-RA does not prevent T-cell activation but rather prevents further T-cell proliferation and differentiation. With the widespread adoption of the present standard triple immunosuppressive regimen, it is now being questioned whether an IL-2RA induction is worth the risk in low immunological risk renal transplant recipients. The present study analyzes the emerging evidence on the efficacy & safety of IL-2RA induction in these recipients.

Methods

A comprehensive literature search was conducted using PubMed for studies involving low immunological risk renal transplant recipients published in last 15 years (2010-2025). All studies including randomized controlled trials, cohort studies and meta-analyses satisfying the above condition were short listed. Out of these only the studies in which at least 2 arms had an IL-2RA induction and no induction respectively were included. Studies which did not stick to the standard triple immunosuppressive regimen or where the dosing regimens were not identical in 2 arms were excluded. Primary endpoints included acute rejection rates, graft survival, patient survival, infection rates, infection types and infectious complications.

Results

IL2-RA induction did not cause any significant reduction in acute rejection up to one year post transplant. Graft survival was also same without induction up to five years. IL2-RA did not impact the patient survival in short term as well as long term. Considerable differences were found in the infections between the two groups. The infection rates were uniformly though non-significantly lower without IL2-RA induction. Specifically, bacterial infectious complications were significantly lower in two to six months period post transplant in the induction free group. Cytomegalovirus infections were found only after IL2-RA induction.

Conclusion

In low immunological risk renal transplant recipients receiving the standard triple immunosuppressive regimen, the IL2-RA induction does not offer any benefit in reducing acute rejection, or increasing graft and patient survival. IL2-RA induction is associated with increased infections and infectious complications up to one year post transplant. The financial impact of hospital stay because of infections gets added to the cost of IL2-RA induction. Omission of IL2-RA induction in low immunological risk renal transplant recipients can make the renal transplant affordable to more patients without impacting survival.

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