Correspondence

Antithymocyte Globulin versus Basiliximab in Renal Transplantation

N Engl J Med 2007; 356:634-635February 8, 2007

Article

To the Editor:

The article by Brennan et al. (Nov. 8 issue),1 comparing rabbit antithymocyte globulin and basiliximab as induction therapy in patients who received a renal transplant from a deceased donor, states that the patients included in the trial were at high risk for acute rejection. The data provided are insufficient to confirm that the subjects were at high immunologic risk, classically defined as a peak panel-reactive antibody value of more than 50% or a current value of more than 30%, the loss of a previous graft through rejection within 12 months after transplantation, the presence of a donor-specific antibody (a positive T-cell or B-cell crossmatch), or a high degree of HLA mismatching. Recent studies have used such criteria to define high immunologic risk for renal allograft recipients.2,3 In the study by Brennan et al., the mean peak panel-reactive antibody value was about 14% in both groups, with a mean value of about 6% at the time of transplantation. No data were provided on the frequency of previous graft loss due to rejection, the frequency of a positive crossmatch, or the degree of HLA mismatching. The provision of such data would enable clinicians to determine the applicability of the results to their own patient populations.

John P. Killen, M.B., B.S.
Steven Chadban, M.B., B.S.
Royal Prince Alfred Hospital, Sydney 2050, Australia
ojpo@hotmail.com

3 References

1. 1

   Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 2006;355:1967-1977
   Full Text | Web of Science | Medline

2. 2

   Zaltzman J, McAlister V, Russell D, et al. Tacrolimus, MMF, steroid, and ALG immunotherapy for high immunological risk renal transplant recipients. Transplant Proc 2001;33:1044-1045
   CrossRef | Web of Science | Medline

3. 3

   Zaltzman JS, Boucher A, Busque S, et al. A prospective 3-yr evaluation of tacrolimus-based immunosuppressive therapy in immunological high risk renal allograft recipients. Clin Transplant 2005;19:26-32
   CrossRef | Web of Science | Medline

Author/Editor Response

Our study enrolled subjects at risk for delayed graft function or acute rejection. Since delayed graft function is an independent risk factor for acute rejection,1 recipients at low risk for delayed graft function were eligible if they had at least one recipient risk factor for rejection. All recipients studied had donor risk factors for delayed graft function, placing them at risk for rejection. A historical peak panel-reactive antibody value of more than 20% was present in 18% of recipients, and a current panel-reactive antibody value of more than 50% was present in 5% of recipients, with no significant differences between the two groups. Reasons for the loss of a previous transplant and the presence of donor-specific antibodies were not recorded. Seven patients received a transplant with a positive B-cell crossmatch, and three also had a positive T-cell crossmatch. Three percent had six HLA mismatches. We believe the study enrolled patients who were at high risk for the period when the study was open. Approximately 50% of kidney transplants from deceased donors in the United States would qualify for a study of this design today, according to data from the United Network for Organ Sharing.

Daniel C. Brennan, M.D.
Washington University School of Medicine, St. Louis, MO 63110
dbrennan@wustl.edu

Paula Buchanan, M.P.H.
Mark A. Schnitzler, Ph.D.
Saint Louis University Center for Outcomes Research, St. Louis, MO 63104

Dr. Buchanan reports receiving a grant from the American Society of Transplantation. Dr. Schnitzler reports receiving consulting fees from Novartis Pharma, lecture fees from Genzyme, and grant support from Genzyme, Novartis Pharma, Astellas, and TransMedics.

1 References

1. 1

   Humar A, Johnson EM, Payne WD, et al. Effect of initial slow graft function on renal allograft rejection and survival. Clin Transplant 1997;11:623-627
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Angela C Webster, Lorenn P Ruster, Richard McGee, Sandra L Matheson, Gail Y Higgins, Narelle S Willis, Jeremy R Chapman, Jonathan C Craig, Angela C Webster. 2010. Interleukin 2 receptor antagonists for kidney transplant recipients. .
   CrossRef