Induction immunosuppressive therapy in renal transplantation in adults
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Washington University School of Medicine
In general, induction immunosuppressive strategies utilized by kidney transplant centers fall into one of two categories (table 1). One strategy relies upon high doses of conventional immunosuppressive agents, while the other utilizes antibodies directed against T-cell antigens in combination with lower doses of conventional agents.
The optimal prophylactic induction immunosuppressive therapy to prevent kidney transplant rejection remains controversial (table 2) [1,2]. What follows in this topic review is a summary of the current data and our approach to induction therapy in adults. Maintenance immunosuppressive therapy is discussed separately. (See "Maintenance immunosuppressive therapy in renal transplantation in adults".)
OVERVIEW OF OUR APPROACH TO INDUCTION THERAPY
Practically all kidney allograft recipients require immunosuppressive therapy to prevent rejection and loss of the allograft. The optimal regimen, including induction therapy, is not clear. A large number of controlled, randomized trials and meta-analyses indicate that induction therapy consisting of biologic antibodies plus conventional immunosuppressive agent therapy is superior to conventional agent therapy alone in reducing kidney allograft rejection and allograft failure [3-5].
Among patients undergoing kidney transplantation, we therefore recommend induction therapy consisting of antibody therapy plus conventional immunosuppressive therapy. One exception is Caucasian recipients of two-haplotype-identical, living, related allografts. Such patients do not generally require induction therapy with antibodies, given their markedly decreased immunologic risk of acute rejection.
Immunosuppressive antibody therapy — Currently available antibodies include the following specific antilymphocyte or interleukin-2 (IL-2) receptor antibodies [5-7]:
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- OVERVIEW OF OUR APPROACH TO INDUCTION THERAPY
- Immunosuppressive antibody therapy
- Nonimmunosuppressive components
- POLYCLONAL ANTIBODIES
- rATG-Thymoglobulin versus Atgam
- rATG-Thymoglobulin compared with IL-2 receptor antibodies
- Dosing strategies for rATG-Thymoglobulin
- How we administer rATG-Thymoglobulin in combination with maintenance therapy
- INTERLEUKIN-2 RECEPTOR ANTIBODIES
- Efficacy of basiliximab compared with rATG-Thymoglobulin
- AUTOLOGOUS MESENCHYMAL STEM CELLS
- UNITED STATES TRENDS
- SUMMARY AND RECOMMENDATIONS