Outcomes of basiliximab vs alemtuzumab induction in kidney allograft recipients with matched immunological Profiles: A retrospective cohort study

Abstract

BACKGROUND

The use of induction immunosuppression agents has improved kidney transplant outcomes, but selecting the optimal agent remains a point of debate.

AIM

To compare the long-term outcomes of kidney transplant recipients receiving alemtuzumab vs basiliximab induction, focusing on graft function, acute rejection, infection, malignancy, post-transplant glomerulonephritis, and survival, using a propensity score matched cohort design.

METHODS

Kidney transplant recipients who received alemtuzumab or basiliximab induction from 2014 to 2019 across two nephrology centres in Northwest England were evaluated. Propensity score matching at a 1:1.5 ratio ensured comparability between cohorts. Baseline characteristics, immunosuppression regimens, and outcomes were analyzed. Linear, binary logistic and Cox proportional hazard regression models.

RESULTS

A total of 436 recipients were included, with a median follow-up of 5.2 years. The matched cohort (n = 262) had a mean age of 51.1 ± 13.5 years; 39% were female and 92% were white. There was no significant difference in the cumulative incidence of acute rejection [odds ratio (OR) = 2.10; 95%CI: 0.9-4.9; P = 0.110]. Compared with basiliximab, alemtuzumab was associated with lower estimated glomerular filtration rate at 12 months (-6.6 mL/minute/1.73 m²; 95%CI: -10.5 to -2.7; P < 0.001) and higher risks of cytomegalovirus viremia (OR = 3.2; 95%CI: 1.6-6.5; P < 0.001), BK viremia (OR = 2.4; 95%CI: 1.1-5.5; P = 0.02), post-transplant malignancy (OR = 6.2; 95%CI: 1.6-29.9; P = 0.013), and death-censored graft loss (hazard ratio = 3.6; 95%CI: 1.2-11.4; P = 0.03). No significant differences were observed in post-transplant glomerulonephritis or recipient mortality.

CONCLUSION

In this propensity score-matched analysis, alemtuzumab induction was associated with lower graft function at 12 months and higher risks of viral infection, post-transplant malignancy, and graft loss compared with basiliximab. These findings highlight the need for further studies to confirm the long-term safety and effectiveness of alemtuzumab in kidney transplantation.

Keywords: Kidney transplantation; Immunosuppression induction; Alemtuzumab; Basiliximab; Graft outcomes

Core Tip: This retrospective cohort study compared real-world outcomes of alemtuzumab and basiliximab induction in kidney transplant recipients from two tertiary centers in North-West England, one routinely using alemtuzumab and the other exclusively basiliximab. Using propensity score matching to reduce confounding, we evaluated graft function, graft and patient survival, acute rejection, infection, and other long-term complications. Alemtuzumab induction was found to be associated with lower estimated glomerular filtration rate, and higher risks of cytomegalovirus and BK viremia, post-transplant malignancy, and death-censored graft loss compared with basiliximab. These findings emphasize the need for individualized selection of induction therapy, balancing the potent immunosuppressive effects of alemtuzumab against its potential for adverse outcomes, and support tailored approaches based on recipient risk profile and center-specific experience.