A 55-year-old man with a remote history of lung cancer underwent living-donor kidney transplant due to end-stage renal disease related to chemotherapy. He is unsensitized and is an Epstein-Barr virus (EBV) mismatch with his donor (i.e. recipient is serologically negative, while donor is serologically positive for both).
Which induction therapy would you recommend and why?
The interleukin-2 receptor antagonist basiliximab binds to the IL-2 receptor and blocks its activation. It does not cause lymphocyte depletion, but does reduce the risk of acute rejection and allows for lower calcineurin inhibitor doses than in patients who do not receive antibody induction.
Thymoglobulin is a polyclonal lymphocyte-depleting antibody, which also allows for lower CnI dosing in the early post-transplant period. In randomized controlled trials in kidney transplantation, patients who receive induction with thymoglobulin have a lower risk of acute rejection compared to those receiving basiliximab. Compared to no induction or an IL-2R antibody, it is associated with an increased risk of infection, particularly CMV, and a greater long-term risk of malignancy, including post-transplant lymphoproliferative disease (PTLD). The risk for PTLD is further increased with an EBV mismatch.
The better choice of induction therapy in an unsensitized patient with history of malignancy and EBV mismatch would be basiliximab.