Sequential biological immunosuppression. Induction therapy with rabbit antithymocyte globulin

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Abstract
This paper describes 108 consecutively treated patients receiving 109 cadaveric (CD) and living donor (LD) renal allografts using a protocol of quadruple sequential immunosuppression with a rabbit anti‐human thymocyte IgG (Thymoglobuline®), azathioprine, tapering corticosteroids, and delayed introduction of cyclosporine A. The average length of induction was 6.1 d with an average Thymoglobuline® dose of 2.0 mg/kg/d. The mean serum creatinine pre‐transplant of the cohort was 877 ± 263 (sd) μmol/L, 146 ± 44 μmol/L by 3 months post‐transplant, and 136 ± 40 μmol/L at 1 yr. The overall 4‐yr actuarial patient survival was 96.6%, and allograft survival was 88.6% at 2 yr and 83.6% at 4 yr. The incidence of acute rejection episodes defined by intention to treat was 32%. Additionally, eight patients in this series received retreatment with Thymoglobuline® for a first acute rejection, and only one of these had a second rejection. This was in contrast to 5/11 recurrent rejections following steroid treatment only, and 5/13 recurrences following OKT3 treatment for the first rejection episode. The side‐effect profile of Thymoglobuline® was largely benign, and the biological agent was well tolerated with initial fever in 75%, chills in 27%, and leucopenia in 22% of the patients. All other drug‐related adverse events had a prevalence of less than 3%, and clinical signs of meningismus were seen in only one patient. There were five associated episodes of CMV. We conclude that Thymoglobuline as part of a quadruple sequential immunosuppressive regimen for renal transplantation is well tolerated and can be associated with a good shortand long‐term outcome of renal transplantation.