Letter to the Editor: Induction therapy as a long-term commitment: Lessons from comparative outcomes of alemtuzumab and basiliximab

Table 1 Evidence-based alignment of induction therapy with recipient risk profiles

Recipient profile	Preferred induction strategy	Clinical rationale and risk-benefit balance	Strength of supporting evidence	Mandatory clinical safeguards
Standard immunologic risk (e.g., first transplant, low PRA, no DSA, well-matched donor)	Basiliximab (IL-2 receptor antagonist)	Preservation of immune competence: Prioritizes long-term safety and graft durability over absolute minimization of early steroids. Avoids profound T-cell depletion in patients with low rejection probability	Moderate-strong (retrospective cohorts, propensity-matched analyses, guideline concordance)	(1) Standard viral surveillance (cytomegalovirus, BK virus); (2) Cautious steroid minimization with close clinical monitoring; and (3) Avoidance of unnecessary maintenance immunosuppression minimization[1,2,11-14,22,23]
High immunologic risk (e.g., re-transplantation, high PRA, DSA positive)	Alemtuzumab (lymphocyte-depleting agent)	Rejection prevention: Accepts higher long-term risks of infection/malignancy to prevent catastrophic early antibody-mediated or cellular rejection	Moderate (RCTs in selected populations, observational studies)	(1) Extended viral surveillance (cytomegalovirus, BK virus PCR beyond the first post-transplant year); (2) Close monitoring for cytopenias and immune reconstitution; and (3) Dynamic reassessment of maintenance immunosuppression[6,7,9,10,17-20]
Frail, elderly, or infection-prone recipients (e.g., age > 65 years, prior malignancy, latent infections)	Basiliximab (conservative strategy)	Safety first: The risk of infection-related mortality or malignancy progression often exceeds the risk of graft loss due to rejection in this demographic	Weak-moderate (retrospective data, expert consensus)	(1) Strict avoidance of lymphocyte-depleting agents; (2) Enhanced malignancy surveillance; and (3) Individualized maintenance immunosuppression targets, often accepting lower trough levels[11,14,15,21,22,23]

PRA: Panel reactive antibody; DSA: Donor-specific antibody; IL: Interleukin; RCT: Randomized control trial; PCR: Polymerase chain reaction.