Kidney Transplant Outcomes With Non-Depleting Antibody Induction Therapy in Human Leucocyte Antigen Sensitised Recipients

TL;DR

The study shows non-depleting antibody therapy works well for kidney transplants in patients with HLA sensitization, with good survival and graft outcomes.

Contribution

Demonstrates non-depleting induction therapy is effective for sensitized kidney transplant recipients, challenging traditional depleting approaches.

Findings

Non-depleting induction therapy achieved 94% allograft survival at 1 year in sensitized recipients.

T cell epitope mismatch scores predicted early rejection risk in transplanted patients.

Highly sensitized patients had lower graft survival compared to unsensitized and sensitized groups.

Abstract

Lymphocyte depleting induction is recommended for kidney transplant recipients (KTRs) at high immunological risk, which traditionally includes those with detectable anti-human leucocyte antigen antibodies. Data to support this approach in the modern era of histocompatibility testing are limited. We investigated outcomes in KTRs who underwent Basiliximab induction between 2012–2023 in the UK. We stratified outcomes by levels of sensitisation and T cell epitope mismatch (PIRCHE-II) scores. 1348 KTRs were included; 859 (63.7%) were unsensitised, 351 (26.0%) sensitised (calculated reaction frequency [cRF] 1%–84%), and 138 (10.3%) highly sensitised (cRF 85%–100%). Patient survival, allograft survival, and death-censored graft survival (DCGS) were 97%, 94%, and 97% at 1 year, and 88%, 78%, and 84% at 5 years respectively. There were no differences in outcomes between unsensitised and sensitised recipients; graft survival was lower in highly sensitised patients. T cell epitope mismatch scores were higher in those with rejection at 1 year (ln[PIRCHE+1] 3.94 ± 1.01 no rejection vs. 4.25 ± 0.58 rejection, p = 0.02) and epitope mismatch was associated with early rejection in multivariable analyses (Odds Ratio 1.58, 95% CI 1.01–2.62). Hence, non-depleting induction provides good outcomes in unsensitised and sensitised KTRs. T cell epitope mismatches inform rejection risk in the first post-transplant year.

Kidney transplant outcomes chart for non-depleting antibody induction in HLA sensitized recipients. Includes retrospective single-centre study in the UK with 1,348 patients under Basiliximab induction. Patient survival: 97% at 1 year, 88% at 5 years; allograft survival: 94% at 1 year, 78% at 5 years, reduced if CRF 85-100%. Sensitisation showed no effect on patient survival. Rejection rates at 12 months are predicted by PIRCHE-II Score, with a bar graph displaying rejection categorized as no rejection, TCMR, or AMR. Chart emphasizes good outcomes with non-depleting induction. Article by Evans et al. in Transplant International 2025.

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