Induction therapy in kidney transplant recipients: A consensus statement of Indian Society of Organ Transplantation

doi:10.5500/wjt.v16.i1.114367

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Mar 18, 2026 (publication date) through Feb 26, 2026

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World Journal of Transplantation

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World J Transplant. Mar 18, 2026; 16(1): 114367
Published online Mar 18, 2026. doi: 10.5500/wjt.v16.i1.114367

Induction therapy in kidney transplant recipients: A consensus statement of Indian Society of Organ Transplantation

Vivek B Kute, Manish Ramesh Balwani, Jigar B Shrimali, Amit Pasari, Vijay Kher, Mohan Punabhai Patel, Deodatta Chafekar, Swarnalata Guditi, Pratik Das, Gireesh Mathihally Siddaiah, Suraj Mohan Godara, Vinant Bhargava, Anurag Gupta, Vishal Ramteke, Nishant Deshpande, Priyanka Tolani, Narayan Prasad, Radhika Krishna Patil, Ravi Mohanka, Sandeep Mahajan, Sourabh Sharma, Subho Banerjee, Divyesh P Engineer, Dhananjai Agarwal, Pranjal Kashiv, Arpita Lahiri, Dinesh Khullar, Aneesh Srivastava

Vivek B Kute, Subho Banerjee, Divyesh P Engineer, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad 380016, Gujarat, India

Manish Ramesh Balwani, Amit Pasari, Department of Nephrology, Saraswati Kidney Care Center, Nagpur 440015, Maharashtra, India

Manish Ramesh Balwani, Amit Pasari, Pranjal Kashiv, Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha 442005, Mahārāshtra, India

Jigar B Shrimali, Department of Nephrology, Renus Kidney Hospital, Ahmedabad 380015, Gujarāt, India

Vijay Kher, Department of Nephrology and Kidney Transplantation, Epitome Kidney Urology Institute and Lions Hospital, New Delhi 110016, Delhi, India

Mohan Punabhai Patel, Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Nashik 422006, Mahārāshtra, India

Deodatta Chafekar, Dr V N Pawar Medical College, Director Supreme Kidney Care, Nashik 422005, Mahārāshtra, India

Swarnalata Guditi, Department of Nephrology, Nizam’s Institute of Medical Sciences, Hyderabad 500082, India

Pratik Das, Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata 700099, West Bengal, India

Gireesh Mathihally Siddaiah, Department of Nephrology, Ramaiah Medical College, Bangalore 560054, Karnātaka, India

Suraj Mohan Godara, Department of Nephrology and Clinical Transplantation, Mahatma Gandhi Medical College and Hospital, Jaipur 302001, Rājasthān, India

Vinant Bhargava, Anurag Gupta, Department of Nephrology, Sir Ganga Ram Hospital New Delhi, New Delhi 110001, New Delhi, India

Vishal Ramteke, Nishant Deshpande, Department of Nephrology, Max Super Speciality Hospital, Nagpur 440030, Mahārāshtra, India

Priyanka Tolani, Department of Internal Medicine, Jawaharlal Nehru Medical College, Wardha 442001, Mahārāshtra, India

Narayan Prasad, Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India

Radhika Krishna Patil, Department of Pathology, Shri Balaji Kidney Care, Hyderabad 500005, Telangāna, India

Ravi Mohanka, Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Maharashtra 400004, India

Sandeep Mahajan, Department of Nephrology, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India

Sourabh Sharma, Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, Delhi, India

Dhananjai Agarwal, Department of Nephrology, SMS Medical College, Jaipur 302001, Rājasthān, India

Arpita Lahiri, Department of Nephrology, Institute of Post Graduate Medical Education & Research and SSKM Hospital, Kolkata 700020, India

Dinesh Khullar, Department of Nephrology and Renal Transplant Medicine, Max Super Speciality Hospital, Saket 110017, New Delhi, India

Aneesh Srivastava, Department of Urology and Renal Transplant, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India

Co-corresponding authors: Manish Ramesh Balwani and Pranjal Kashiv.

Author contributions: Balwani MR and Kashiv P served as co-corresponding authors as both played equally critical and complementary roles in conceptualizing, supervising, coordinating, and finalizing the study. Balwani MR oversaw the scientific design, multicentre coordination, and methodological integrity of the project, while Kashiv P coordinated national data acquisition, validation, manuscript drafting, and correspondence with the editorial office. Both contributed equally to data interpretation, revisions, and final approval, justifying co-corresponding authorship; Kute VB and Balwani MR conceptualized and designed the research; Shrimali JB, Pasari A, Kher V, Patel MP, Chafekar D, Guditi S, Das P, Gireesh MS, Godara SM, Bhargava V, Gupta A, Ramteke VV, Deshpande NS, Tolani P, Khullar D, Prasad N, Patil RK, Mohanka R, Mahajan S, Sharma S, Banerjee S, Engineer DP, Agarwal D, Kashiv P, Lahiri A, and Srivastava A performed the research through survey design, literature review, consensus panel participation, and expert clinical input; Tolani P and Kashiv P analyzed and collated data; Kute VB, Balwani MR, Pasari A, and Shrimali JB wrote the initial draft of the manuscript; Kher V, Khullar D, Mahajan S, Prasad N, and Mohanka R critically revised the manuscript for scientific accuracy and national representation; all authors read and approved the final version of the paper.

Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.

Corresponding author: Manish Ramesh Balwani, DM, MD, Professor, Department of Nephrology, Saraswati Kidney Care Center, 13, Jaitala Road, Near Jaiprakash Nagar Metro Station, New Sneh Nagar, Nagpur 440015, Maharashtra, India. balwani.manish@yahoo.com

Received: September 17, 2025
Revised: September 27, 2025
Accepted: November 26, 2025
Published online: March 18, 2026
Processing time: 119 Days and 16.9 Hours

Abstract

Kidney transplantation (KT) accounts for nearly three-fourths of organ transplants in India, with living donors contributing to 82% of cases. Induction immunosuppression is essential to optimize initial immunosuppression, reduce acute rejections, and enable tailored use of maintenance agents. Rabbit anti-thymocyte globulin (rATG) and interleukin-2 receptor anatagonists (IL-2RA/IL-2RBs) are the most widely used induction therapies. However, data on induction practices across India are limited. To evaluate induction immunosuppression practices across KT centers in India and establish a consensus for different subsets of KT recipients. A nationwide online survey was conducted by the Indian Society of Organ Transplantation (ISOT) among its members (400 KT centers). Responses were analyzed to assess induction practices across diverse donor types, age groups, and immunological risk profiles. Heterogeneity in practices prompted consensus building using a modified Delphi process. Literature review and expert panel discussions (April 2024) were followed by structured voting, and 16 consensus statements were finalized. Of 400 centers approached, 254 participated. rATG was the most commonly used induction therapy, followed by IL-2RBs; alemtuzumab was least used. Significant heterogeneity was observed in type, dose, and duration of induction therapy. Consensus recommendations were framed: rATG for high immunological risk recipients and deceased donor KTs; IL-2RB or low-dose rATG for low immunological risk; rituximab in ABO-incompatible KTs; and tailoring based on age, diabetes, donor type, infection risk, and affordability. This first ISOT consensus provides 16 India-specific statements on induction therapy in KT. It emphasizes risk-stratified, evidence-informed, and context-appropriate induction strategies, supporting standardization of care across the country.

Keywords: Kidney transplant; Induction therapy; Rabbit anti-thymocyte globulin; IL-2 receptor blockers; Rituximab; Consensus; Indian Society of Organ Transplantation

Core Tip: Kidney transplantation is the most common solid organ transplantation in India, yet induction immunosuppression practices vary widely across centers. The Indian Society of Organ Transplantation (ISOT) conducted a nationwide survey and identified significant heterogeneity in induction therapy choice, dose, and duration. Through a structured Delphi consensus, ISOT developed 16 statements to guide practice. Rabbit anti-thymocyte globulin (rATG) remains the preferred induction for high immunological risk and deceased donor recipients, while interleukin-2 receptor anatagonists or low-dose rATG is suitable for low-risk cases. Rituximab is recommended for ABO-incompatible transplants. These India-specific guidelines provide a standardized framework to optimize patient outcomes and rationalize induction therapy.