To Induce or Not To Induce: A 21st Century Evaluation of Lung Transplant Immunosuppression

• Published in: The Journal of heart and lung transplantation Vol. 32; no. 4; p. S88
• Main Authors: Whitson, B.A, Lehman, A, Wehr, A, Hayes, D, Kirkby, S, Pope-Harman, A, Kilic, A, Higgins, R.S.D
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.04.2013
• Subjects: Surgery
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2013.01.224

Purpose The impact of induction immunosuppression on lung transplant (LTX) recipients survival is unclear. We sought to evaluate the effect of contemporary induction agents in LTX recipients with the primary endpoint of survival and a secondary endpoint of treated rejection in the first year post-transplant (TR1Y). Methods and Materials We queried the UNOS registry for LTX from 1987-2012. We restricted our analysis to adults (>=18 years), cadaveric LTX performed from 2001-2012 who received either: no antibody based induction (NONE) or the contemporary agents of either basiliximab, alemtuzumab, thymoglobulin, ALG or ATG (INDUCED). Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models compared survival. Results Of LTX recipients, 12958 meet the inclusion criteria & 5747 (44%) were INDUCED. Of INDUCED agents, 62% were basiliximab, 14% alemtuzumab, and 23% ALG/ATG/Thymo. Being INDUCED increased survival (p<0.001). [ Figure 1 ] Median INDUCED survival was 73.4 months (95%CI: 61.8–79 months) and 63.9 months (95%CI: 60.6–66.7 months) for NONE. Basiliximab had survival superior to ALG/ATG/Thymo (p=0.03). In multivariable analysis, INDUCED had a protective effect for all diagnoses except IPF. Of INDUCED patients, 34% were TR1Y & 38% with NONE (p<0.001; note 31% of TR1Y data were uncoded; multiple imputation to assess the impact). There was no effect on dialysis rate (INDUCED, 5%; NONE 6%,p=0.9). Conclusions In a contemporary analysis of LTX recipients, induction immunosuppression has a significantly increased survival. Being INDUCED has less incidence of rejection with no effect on the need for dialysis. Hazard Ratios for INDUCED vs. NONE HR 95% CI p CF 0.69 0.58-0.82 <.001 COPD 0.88 0.8-0.97 0.008 IPF 0.94 0.85-1.04 0.25 Other 0.77 0.68-0.86 <.001