Inducing All Our ‘Low-Risk’ Transplant Candidates: Shall We Or Shall We Not?

Acute rejection episode (ARE) in an allograft recipient has a negative impact on graft survival, and therefore, preventing ARE is of paramount importance. Induction by antibody preparations is one such strategy that has been proven effective in preventing AREs, but there are certain ambiguities in their use particularly in low immunological risk transplants. Anti-interleukin-2 receptor therapy had gained widespread usage in this group of patients because it does not incur additional risks of infectious and malignant sequelae associated with thymoglobulin. However, recent literature found it to be no better than “no induction” strategy. Thymoglobulin, being frequently used in North America for induction even in low risk group, has been used in variable doses across transplant centers. The minimal possible dose of Thymoglobulin that avoids majority of adverse effects while retaining an optimal treatment benefit has not been clearly defined. Moreover, the effects of induction by antibody preparations on long term graft function and survival remain variable. Majority of the published work on induction immunosuppression is retrospective and is difficult to interpret because of a wide spectrum of maintenance immunosuppressive regimen in vogue. This review of literature has been performed to analyse published literature to assess the efficacy and appropriateness of induction agents in “low risk” transplants. We suggest that ‘low-risk patients receiving triple-drug immunosuppression(calcineurin inhibitors, an anti-proliferative agent and steroids) do not need ‘routine' induction by antibody preparations.