Galassi L, Altamura E, Azzahrani L, Facchinetti F, Ravini ML. Letter to the Editor: Induction therapy as a long-term commitment: Lessons from comparative outcomes of alemtuzumab and basiliximab. World J Transplant 2026; 16(2): 118962 [DOI: 10.5500/wjt.v16.i2.118962]
Corresponding Author of This Article
Luca Galassi, MD, Lecturer, Researcher, Postgraduate School of Vascular and Endovascular Surgery, University of Milan, Festa del Perdono Street, Milan 20122, Lombardy, Italy. luca.galassi@unimi.it
Research Domain of This Article
Surgery
Article-Type of This Article
letter
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Galassi L, Altamura E, Azzahrani L, Facchinetti F, Ravini ML. Letter to the Editor: Induction therapy as a long-term commitment: Lessons from comparative outcomes of alemtuzumab and basiliximab. World J Transplant 2026; 16(2): 118962 [DOI: 10.5500/wjt.v16.i2.118962]
Luca Galassi, Postgraduate School of Vascular and Endovascular Surgery, University of Milan, Milan 20122, Lombardy, Italy
Erica Altamura, School of Medicine and Surgery, University of Milan, Milan 20122, Lombardy, Italy
Lina Azzahrani, School of Health Studies, University of Western Ontario, London N6A 3K7, Ontario, Canada
Federica Facchinetti, School of Medicine and Surgery, University of Milan-Bicocca, Monza 20900, Lombardy, Italy
Matteo Lino Ravini, Vascular and Endovascular Unit, IRCCS Ospedale Galeazzi - Sant’Ambrogio, Milan 20157, Lombardy, Italy
Co-corresponding authors: Luca Galassi and Erica Altamura.
Author contributions: Galassi L, Altamura E, Azzahrani L, Facchinetti F, and Ravini ML contributed to writing - review and editing; Galassi L, Altamura E, and Facchinetti F contributed to methodology, writing - original draft preparation; Galassi L, Altamura E, Facchinetti F, and Ravini ML contributed to conceptualization, Galassi L, Facchinetti F, and Ravini ML contributed to validation; Galassi L and Altamura E contributed equally to this manuscript and are co-corresponding authors. All authors have read and agreed to the published version of the manuscript.
AI contribution statement: The manuscript was not generated using artificial intelligence tools. However, standard digital tools embedded in word processing software have been used for basic grammar and spelling checks during the revision process, as is common in academic writing.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Luca Galassi, MD, Lecturer, Researcher, Postgraduate School of Vascular and Endovascular Surgery, University of Milan, Festa del Perdono Street, Milan 20122, Lombardy, Italy. luca.galassi@unimi.it
Received: January 15, 2026 Revised: February 9, 2026 Accepted: March 9, 2026 Published online: June 18, 2026 Processing time: 134 Days and 14.3 Hours
Abstract
Induction immunosuppression in kidney transplantation requires a longitudinal perspective that extends beyond early rejection prevention to encompass long-term graft durability and patient safety. In response to the recent propensity score-matched study by Chukwu et al, complementary considerations are provided that address two underrecognized dimensions: Cumulative immunological burden and the downstream interaction between induction strategies and maintenance immunosuppression. Potent lymphocyte-depleting agents, despite comparable short-term rejection rates, are associated with a disproportionate “immunological debt” in standard-risk recipients, manifested by increased viral complications, malignancy, impaired graft function, and inferior death-censored graft survival. In contrast, non-lymphocyte-depleting induction preserves immune competence while maintaining adequate rejection control in this population. The integration of strict risk stratification, extended surveillance protocols, and dynamic reassessment of maintenance immunosuppression into standardized induction pathways is essential to optimize long-term outcomes. Framing induction therapy as a long-term commitment rather than a perioperative intervention supports alignment of immunosuppressive intensity with recipient risk and sustained graft stewardship.
Core Tip: The choice of induction therapy in kidney transplantation has commonly been centered around short-term rejection outcomes, which do not reliably predict the long-term safety and graft outcomes. Evidence reveals that, despite similar rejection rates, alemtuzumab is associated with increased risks of infection and malignancy and reduced graft survival among standard-risk recipients. These data support a risk-stratified approach to induction therapy, advocating non-lymphocyte-depleting agents for standard-risk patients and reserving lymphocyte-depleting induction for selected high-risk recipients.
