ABSTRACT
Introduction: Anti Thymocyte Globulin(ATG) is very effective as an Induction and antirejection therapy (ART) agent in renal Transplantation. Equine ATG (eATG) has been used less compared to rabbit ATG(rATG) in tranplantation. Cost of eATG as induction agent is 200 USD, in comparison to rATG, which costs minimum 700 USD per dose (approximately four times more than eATG). Experience with eATG initially was not good because of drug reactions but over the years the molecule has evolved into a better drug and is the preferred drug over rATG in severe Aplastic Anemia without any reactions. Covid pandemic has affected the supply chain of rATG because of vaccine production leading to shortage of rATG. Hence eATG is the only available ATG. Method(s): We present our experience with eATG in a tertiary care nephrology centre for the last 95 renal transplants. Patients have been divided into two groups. Group A- contained HLA matched first degree relatives as renal donors and induction agent was injection Methylprednisolone (MP). Group B- Had Recipients of Deceased or Spousal donors and received eATG 10mg/kg as induction agent single dose. Monitoring of renal function and observation for complications including, infections was done. Blood lymphocyte count was monitored for intial 2 weeks to look for lymphocyte depletion as an indicator of eATG efficacy. Patients were followed upto 5 years post transplant (PTX) and assessment was done at 1,3 and 5 years for graft and patient survival. eATG usage as anti rejection therapy (ART) agent in acute T- cell-mediated rejection(TCMR) : All acute TCMRs (biopsy proved) were treated with eATG 10mg/kg body for 5 consecutive days followed by repeat biopsy and additional eATG therapy depending on patient response. Result(s): Induction Therapy: Table 1,2,3 Number of recipients in GrA were 41 and GrB were 54. Marked decrease in Lymphocyte count in Gr B indicated efficacy of eATG (p<0.05). In the first 90 days post transplant, Acute TCMR ( biopsy proved) was seen in 5(9.7 %) of GrA and 7(12.9 %) of GrB (p>0.05). In GrA 1(2.4%) patient had acute antibody mediated rejection (ABMR) but could not be treated with ART because of presence of active infection. In Gr B 1(1.8%) patient had histopathological features suggestive of ABMR but was C4D negative and patient responded to eATG alone. Infections were noticed in 9.7% (5/41) of GrA patients and 11.1% (6/54) of GrB patients in the first 180 days PTX (p>0.05). Urinary tract infections, respiratory tract infections and soft tissue infections were commonly seen. Post ART oppurtunistic infections were not seen. Comparison of incidence of Acute rejection rates, graft survival, complications rate and patient survival rate show similar results in both the groups. We achieved good efficacy with eATG as induction and ART agent in biopsy proved acute TCMR. No adverse events and no malignancies were observed after eATG therapy. Conclusion(s): eATG can be used as induction and antirejecton therapy agent in TCMR in renal transplantation. eATG is economical compared to rATG. No conflict of interestCopyright © 2023
ABSTRACT
BACKGROUND: Equine Anti-Thymocyte Immunoglobulin (eATG) has been used less as an induction immunosuppressant agent in renal transplantation compared to rabbit ATG (rATG). However, eATG is very economical compared to rATG. The cost of eATG as induction agent in renal transplant on an average is INR. 30 000/- per dose, and cost of rabbit ATG ( rATG) as induction agent is INR 1 20 000/-. AIM OF THE STUDY: To study the efficacy of eATG as induction and anti-rejection therapeutic agent in renal transplantation. METHOD(S): Material(s) and Method(s): Renal transplant recipients were divided into two groups. Group A (GrA) recipients had renal donation from HLA matched first degree relatives and received only injection methylprednisolone (MP) as induction therapy. Group B (GrB) recipients had renal donation from deceased donors (brain dead) or spousal donors were administered eATG 10 mg/kg along with low dose MP as induction therapy. Outcomes were compared between GrA and GrB. Monitoring for eATG therapy-induced blood lymphocyte count depletion post-transplant was also done to assess eATG efficacy. eATG as antirejection therapy agent: eATG was administered in biopsy-proved acute T-cell-mediated rejection (TCMR). Repeat transplant kidney biopsy was done to assess improvement. RESULT(S): Number of renal transplant recipients in GrA were 29 and GrB were 35. All recipients of GrA and GrB had normal renal function by 14th post-transplant day (PTX). There was 20% decrease in blood lymphocyte count following MP therapy (GrA) compared to 85% decrease following therapy with eATG ( GrB) and the difference was statistically significant (p < 0.05). Marked decrease in lymphocyte count indicated efficacy of eATG. Biopsy-proved acute TCMR was seen in 5% of GrA and 4% of GrB (p > 0.05). None from both groups had antibody mediated rejection. All patients with acute TCMR responded to eATG antirejection therapy. Opportunistic infections was noticed in 9% of GrA patients and 11% of GrB patients in the first 180 days PTX (p > 0.05). Two years graft survival was 83% in GrA and 80% in GrB (p > 0.05). During two-year followup one patient from each group died of Covid19 infection (p > 0.05). CONCLUSION(S): Since excellent results were obtained with eATG as an induction and antirejection therapeutic agent, it can be used in renal transplant with high-risk immunological states as a polyclonal antibody. eATG is more economical compared to rATG.