Use of Thymoglobulin<sup>®</sup> (antithymocyte immunoglobulin) in renal transplantation: practical guide

Castro, Maria Cristina Ribeiro de; Deboni, Luciane; Esmeraldo, Ronaldo de Matos; Matuk, Tereza Azevedo; Pacheco, Alvaro; Saitovitch, David; Salomão, Abrahão; Silva Junior, Helio Tedesco; Villaça, Sandra

doi:10.5935/0101-2800.20150036

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Brasil

Brazilian Journal of Nephrology

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Review Article • J. Bras. Nefrol. 37 (2) • Apr-Jun 2015 • https://doi.org/10.5935/0101-2800.20150036 copy

Use of Thymoglobulin^® (antithymocyte immunoglobulin) in renal transplantation: practical guide

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The combination of immunosuppressive drugs is part of the treatment regimen of patients undergoing kidney transplantation (RT). Thymoglobulin^®, a rabbit immunoglobulin directed against human thymocytes, is the most commonly agent used for induction therapy in RT in the US. In Brazil, Thymoglobulin^® is approved by ANVISA for the use in patients who underwent kidney transplantation and despite being widely used, there are controversies regarding the drug administration. We prepared a systematic review of the literature, evaluating studies that used Thymoglobulin^® for induction and for acute rejection treatment in patients undergoing RT. The review used the computadorized databases of EMBASE, LILACS and MedLine. Data were extracted from the studies concerning general features, methodological characteristics and variables analyzed in each study. From the results, a practical guide was prepared analyzing various aspects on the use of Thymoglobulin^® in patients submitted to RT.

Keywords:
antilymphocyte serum; immunoglobulins, intravenous; kidney transplantation

Study	Reasons for exclusion
Chaparro et al. 2009³⁹39 Chaparro A, Monteverde M, Ibañez J, Adragna M, Lopez L, Briones L, et al. Trasplante renal 1988 - 2008. Med Infant 2009;16:118-25.	Not randomized
Díaz et al. 2008⁴⁰40 Díaz JM, Cabera C, Facundo C, Guirado L, Maderuelo A, Silva I, et al. Evolución de los pacientes trasplantados con riñones procedentes de donantes en asistolia. Actas Fund Puigvert 2008;27:127-30.	Not randomized
Kuypers et al.2005⁴¹41 Kuypers DR, Malaise J, Claes K, Evenepoel P, Maes B, Coosemans W, et al.; Euro-SPK Study Group. Secondary effects of immunosuppressive drugs after simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2005;20:33-9.	Kidney/pancreas transplants
Mehrabi et al. 2007⁴²42 Mehrabi A, Mood ZhA, Sadeghi M, Schmied BM, Müller SA, Welsch T, et al. Thymoglobulin and ischemia reperfusion injury in kidney and liver transplantation. Nephrol Dial Transplant 2007;22:viii54-viii60. DOI: http://dx.doi.org/10.1093/ndt/gfm651 http://dx.doi.org/10.1093/ndt/gfm651...	Not randomized
Agha et al. 2002⁴³43 Agha IA, Rueda J, Alvarez A, Singer GG, Miller BW, Flavin K, et al. Short course induction immunosuppression with thymoglobulin for renal transplant recipients. Transplantation 2002;73:473-5. DOI: http://dx.doi.org/10.1097/00007890-200202150-00025 http://dx.doi.org/10.1097/00007890-20020...	Not randomized
Moura et al. 2006⁴⁴44 Moura LRR, Pereira MG, Durão M, Tomato EJ, Matos ACC, Wroclawski ER, et al. Imunoglobulina antitimócito como terapia de indução: proteção contra a lesão de isquemia e reperfusão. Einstein (São Paulo) 2006;4:315-20.	Not randomized
Nicoluzzi et al. 2010⁴⁵45 Nicoluzzi JE, Silveira F, Silveira FP, Macri M. Experience with 100 pancreas transplants. Rev Col Bras Cir 2010;37:102-5. DOI:http://dx.doi.org/10.1590/S0100-69912010000200006 http://dx.doi.org/10.1590/S0100-69912010...	Pancreas transplants
Sampaio et al. 2010⁴⁶46 Sampaio ELM, Freitas TVD, Galante NZ, Park SI, Harada KM, Haolla FAB, et al. Terapia de indução com alentuzumabe em receptores de transplante renal. J Bras Nefrol 2010;32:91-9. DOI: http://dx.doi.org/10.1590/S0101-28002010000100015 http://dx.doi.org/10.1590/S0101-28002010...	Not randomized
Sancho et al. 2006⁴⁷47 Sancho A, Gavela E, Crespo JF, Górriz JL, Ávila A, Núñez A, et al. Renal transplantation with positive cross-matching test. Nefrologia 2006;26:261-6.	Not randomized
Laftavi et al. 2011⁴⁸48 Laftavi MR, Patel S, Soliman MR, Alnimri M, Kohli R, Said M, et al. Low-dose thymoglobulin use in elderly renal transplant recipients is safe and effective induction therapy. Transplant Proc 2011;43:466-8. PMID: 21440735 DOI: http://dx.doi.org/10.1016/j.transproceed.2011.01.039 http://dx.doi.org/10.1016/j.transproceed...	Not randomized
Anil Kumar et al. 2008⁴⁹49 Anil Kumar MS, Irfan Saeed M, Ranganna K, Malat G, Sustento-Reodica N, Kumar AM, et al. Comparison of four different immunosuppression protocols without long-term steroid therapy in kidney recipients monitored by surveillance biopsy: five-year outcomes. Transpl Immunol 2008;20:32-42. DOI: http://dx.doi.org/10.1016/j.trim.2008.08.005 http://dx.doi.org/10.1016/j.trim.2008.08...	Did not assess anti-thymocyte globulin
Ciancio et al. 2008⁵⁰50 Ciancio G, Burke GW, Gaynor JJ, Roth D, Sageshima J, Kupin W, et al. Randomized trial of mycophenolate mofetil versus enteric-coated mycophenolate sodium in primary renal transplant recipients given tacrolimus and daclizumab/thymoglobulin: one year follow-up. Transplantation 2008;86:67-74.	Did not assess anti-thymocyte globulin
Buchler et al. 2007⁵¹51 Büchler M, Caillard S, Barbier S, Thervet E, Toupance O, Mazouz H, et al.; SPIESSER Group. Sirolimus versus cyclosporine in kidney recipients receiving thymoglobulin, mycophenolate mofetil and a 6-month course of steroids. Am J Transplant 2007;7:2522-31. DOI:http://dx.doi.org/10.1111/j.1600-6143.2007.01976.x http://dx.doi.org/10.1111/j.1600-6143.20...	Did not assess anti-thymocyte globulin
Aoun et al. 2007⁵²52 Aoun M, Eschewege P, Hamoudi Y, Beaudreuil S, Duranteau J, Cheisson G, et al. Very early steroid withdrawal in simultaneous pancreas-kidney transplants. Nephrol Dial Transplant 2007;22:899-905. DOI: http://dx.doi.org/10.1093/ndt/gfl660 http://dx.doi.org/10.1093/ndt/gfl660...	Kidney/pancreas transplants
Bogetti et al. 2005⁵³53 Bogetti D, Sankary HN, Jarzembowski TM, Manzelli A, Knight PS, Thielke J, et al. Thymoglobulin induction protects liver allografts from ischemia/reperfusion injury. Clin Transplant 2005;19:507-11. DOI: http://dx.doi.org/10.1111/j.1399-0012.2005.00375.x http://dx.doi.org/10.1111/j.1399-0012.20...	Liver transplants
Hardinger et al. 2005⁵⁴54 Hardinger KL, Bohl DL, Schnitzler MA, Lockwood M, Storch GA, Brennan DC. A randomized, prospective, pharmacoeconomic trial of tacrolimus versus cyclosporine in combination with thymoglobulin in renal transplant recipients. Transplantation 2005;80:41-6. PMID: 16003231 DOI:http://dx.doi.org/10.1097/01.TP.0000162980.68628.5A http://dx.doi.org/10.1097/01.TP.00001629...	Did not assess anti-thymocyte globulin
Lo et al. 2004⁵⁵55 Lo A, Egidi MF, Gaber LW, Shokouh-Amiri MH, Nazakatgoo N, Fisher JS, et al. Observations regarding the use of sirolimus and tacrolimus in high-risk cadaveric renal transplantation. Clin Transplant 2004;18:53-61. DOI: http://dx.doi.org/10.1111/j.1399-0012.2004.00116.x http://dx.doi.org/10.1111/j.1399-0012.20...	Did not assess anti-thymocyte globulin
Stegall et al. 2003⁵⁶56 Stegall MD, Larson TS, Prieto M, Gloor J, Textor S, Nyberg S, et al. Kidney transplantation without calcineurin inhibitors using sirolimus. Transplant Proc 2003;35:125S-7S. DOI: http://dx.doi.org/10.1016/S0041-1345(03)00226-4 http://dx.doi.org/10.1016/S0041-1345(03)...	Did not assess anti-thymocyte globulin
Kim et al. 2012⁵⁷57 Kim JM, Jang HR, Ko JS, Kwon CH, Kwak MS, Hur WS, et al. Comparison between thymoglobulin and ATGAM as an induction agent in adult kidney transplantation: a single-center experience. Transplant Proc 2012;44:171-4. DOI: http://dx.doi.org/10.1016/j.transproceed.2011.11.061 http://dx.doi.org/10.1016/j.transproceed...	Not randomized
LaMattina et al. 2012⁵⁸58 LaMattina JC, Mezrich JD, Hofmann RM, Foley DP, D'Alessandro AM, Sollinger HW, et al. Alemtuzumab as compared to alternative contemporary induction regimens. Transpl Int 2012;25:518-26. DOI: http://dx.doi.org/10.1111/j.1432-2277.2012.01448.x http://dx.doi.org/10.1111/j.1432-2277.20...	Not randomized
Ciancio et al. 2011⁵⁹59 Ciancio G, Gaynor JJ, Sageshima J, Guerra G, Zarak A, Roth D, et al. Randomized trial of dual antibody induction therapy with steroid avoidance in renal transplantation. Transplantation 2011;92:1348-57. PMID: 22027927 DOI: http://dx.doi.org/10.1097/TP.0b013e3182384b21 http://dx.doi.org/10.1097/TP.0b013e31823...	Did not assess anti-thymocyte globulin
Hourmant et al. 1994⁶⁰60 Hourmant M, Le Mauff B, Cantarovich D, Dantal J, Baatard R, Denis M, et al. Prevention of acute rejection episodes with an anti-interleukin 2 receptor monoclonal antibody. II. Results after a second kidney transplantation. Transplantation 1994;57:204-7. PMID: 8310508 DOI:http://dx.doi.org/10.1097/00007890-199401001-00008 http://dx.doi.org/10.1097/00007890-19940...	Not randomized
Martin et al. 2011⁶¹61 Martin ST, Roberts KL, Malek SK, Tullius SG, Vadivel N, De Serres S, et al. Induction treatment with rabbit antithymocyte globulin versus basiliximab in renal transplant recipients with planned early steroid withdrawal. Pharmacotherapy 2011;31:566-73. DOI: http://dx.doi.org/10.1592/phco.31.6.566 http://dx.doi.org/10.1592/phco.31.6.566...	Not randomized
Thielke et al. 2005⁶²62 Thielke J, DeChristopher PJ, Sankary H, Oberholzer J, Testa G, Benedetti E. Highly successful living donor kidney transplantation after conversion to negative of a previously positive flow-cytometry cross-match by pretransplant plasmapheresis. Transplant Proc 2005;37:643-4. PMID: 15848486 DOI:http://dx.doi.org/10.1016/j.transproceed.2004.12.063 http://dx.doi.org/10.1016/j.transproceed...	Not randomized
Ulrich et al. 2011⁶³63 Ulrich F, Niedzwiecki S, Pascher A, Kohler S, Weiss S, Fikatas P, et al. Long-term outcome of ATG vs. Basiliximab induction. Eur J Clin Invest 2011;41:971-8. DOI: http://dx.doi.org/10.1111/j.1365-2362.2011.02490.x http://dx.doi.org/10.1111/j.1365-2362.20...	Not randomized

	Type of study	Comparison	N	Acute rejection rate	Chronic injury rate	Delayed graft function	Survival (+ 6-12 months)	Graft survival (+ 6-12 months)	Graft loss rate
Ciancio et al. 2010⁶⁴64 Ciancio G, Gaynor JJ, Roth D, Kupin W, Hanson L, Tueros L, et al. Randomized trial of thymoglobulin versus alemtuzumab (with lower dose maintenance immunosuppression) versus daclizumab in living donor renal transplantation. Transplant Proc 2010;42:3503-6. PMID: 21094804 DOI:http://dx.doi.org/10.1016/j.transproceed.2010.08.045 http://dx.doi.org/10.1016/j.transproceed...	RCT, live donors	ATG vs. Alemtuzumab vs. Daclizumab	13	0 (0%)	0 (0%)	2 (15.3%)	NR	NR	0 (0%)
			13	1 (769%)	3 (23.%)	0 (0%)			0 (0%)
			12	1 (8.33%)	0 (0%)	0 (0%)			0 (0%)
					p = 0.01
Brennan et al. 199 9²¹21 Brennan DC, Flavin K, Lowell JA, Howard TK, Shenoy S, Burgess S, et al. A randomized, double-blinded comparison of Thymoglobulin versus Atgam for induction immunosuppressive therapy in adult renal transplant recipients. Transplantation 1999;67:1011-8. PMID: 10221486 DOI:http://dx.doi.org/10.1097/00007890-199904150-00013 http://dx.doi.org/10.1097/00007890-19990...	RCT,deceased donors	ATG vs. Atgam	48	2 (4.2%)	NR	1/72 (1%)	47 (98%)	47 (98%)	0 (0%)
							23 (96%)	20 (83%)	3 (13%)
			24	6 (25%)			p = 0.606	p = 0.020
				p = 0.014
Brennan et al. 2006¹³13 Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D; Thymoglobulin Induction Study Group. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 2006;355:1967-77. DOI: http://dx.doi.org/10.1056/NEJMoa060068 http://dx.doi.org/10.1056/NEJMoa060068...	RCT,deceased donors	ATG vs. Basiliximab	141	22 (15.6%)	NR	57 (40.4%)	135 (95.7%)	128 (90.8%)	13 (9.2%)
							131 (95.6%)	123 (89.8%)	14 (10.2%)
			137	35 (25.5%)	NR	61 (45.5%)	p = 0.90		p = 0.68
				p = 0.02		p = 0.54
Noëlet al. 2009⁸8 Noël C, Abramowicz D, Durand D, Mourad G, Lang P, Kessler M, et al. Daclizumab versus antithymocyte globulin in high-immunological-risk renal transplant recipients. J Am Soc Nephrol 2009;20:1385-92. DOI: http://dx.doi.org/10.1681/ASN.2008101037 http://dx.doi.org/10.1681/ASN.2008101037...	RCT,deceased donors	ATG vs. Daclizumab	113	17 (15%)	NR	35 (31.5%)	108 (95.6%)	93 (82.3%)	20 (177%)
							110 (96.5%)	98 (86.0%)	16 (14%)
			114	31 (27.2%)		50 (44.6%)	p = 0.75	p = 0.47	p = 0.47
				p = 0.016		p = 0.044
Mourad et al. 2004²³23 Mourad G, Rostaing L, Legendre C, Garrigue V, Thervet E, Durand D. Sequential protocols using basiliximab versus antithymocyte globulins in renal-transplant patients receiving mycophenolate mofetil and steroids. Transplantation 2004;78:584-90. PMID: 15446319 DOI:http://dx.doi.org/10.1097/01.TP.0000129812.68794.CC http://dx.doi.org/10.1097/01.TP.00001298...	RCT deceased or live donors	ATG vs. Basiliximab	53	5 (9.4%)	NR	16 (30%)	51 (98.1%)	50 (96.2%)	2 (3.8%)
							52 (98.1%)	50 (94.2%)	2 (3.9%)
			52	5 (9.6%)		15 (28%)
Abou-Ayache et al. 2008²⁶26 Abou-Ayache R, Büchler M, Lepogamp P, Westeel PF, Le Meur Y, Etienne I, et al. CMV infections after two doses of daclizumab versus thymoglobulin in renal transplant patients receiving mycophenolate mofetil, steroids and delayed cyclosporine A. Nephrol Dial Transplant 2008;23:2024-32. DOI: http://dx.doi.org/10.1093/ndt/gfm873 http://dx.doi.org/10.1093/ndt/gfm873...	RCT,deceased donors	ATG vs. Daclizumab	55	8 (14.5%)	NR	20 (36%)	54 (98%)	52 (95%)	NR
							53 (98%)	51 (94%)
			54	9 (16.7%)		17 (32%)
				p = NS
Ciancio et al. 2005/2008²⁷27 Ciancio G, Burke GW, Gaynor JJ, Carreno MR, Cirocco RE, Mathew JM, et al. A randomized trial of three renal transplant induction antibodies: early comparison of tacrolimus, mycophenolate mofetil, and steroid dosing, and newer immune-monitoring. Transplantation 2005;80:457-65. PMID: 16123718 DOI: http://dx.doi.org/10.1097/01.tp.0000165847.05787.08 http://dx.doi.org/10.1097/01.tp.00001658... ^,⁶⁵65 Ciancio G, Burke GW, Gaynor JJ, Roth D, Kupin W, Rosen A, et al. A randomized trial of thymoglobulin vs. alemtuzumab (with lower dose maintenance immunosuppression) vs. daclizumab in renal transplantation at 24 months of follow-up. Clin Transplant 2008;22:200-10. DOI:http://dx.doi.org/10.1111/j.1399-0012.2007.00774.x http://dx.doi.org/10.1111/j.1399-0012.20...	RCT,deceased donors	ATG vs. Alemtuzumab vs. Daclizumab	30	6 (17%)	5 (14%)	4 (13.3%)	25 (85%)	24 (81%)	1 (3.33%)
							26 (88%)	22 (74%)	6 (20%)
			30	7 (24%)	11 (37%)	2 (6.7%)	25 (85%)	24 (82%)	1 (3.33%)
							p = 0.89	p = 0.66
			30	7 (25%)	3 (11%)	2 (6.7%)
					p = 0.02	p = 0.58
Khosroshahi et al. 2008¹¹11 Khosroshahi HT, Tubbs RS, Shoja MM, Ghafari A, Noshad H, Ardalan MR. Effect of prophylaxis with low-dose anti-thymocyte globulin on prevention of acute kidney allograft rejection. Transplant Proc 2008;40:137-9. PMID: 18261569 DOI: http://dx.doi.org/10.1016/j.transproceed.2007.12.016 http://dx.doi.org/10.1016/j.transproceed...	RCT, live donors	Immunosuppression # vs. Immunosuppression # + ATG	37	12 (32.4%)	NR	NR	NR	NR	0 (0%)
									1 (3.22%)
			31	4 (12.9%)
				p = 0.05
Farney et al. 2008⁵5 Farney A, Sundberg A, Moore P, Hartmann E, Rogers J, Doares W, et al. A randomized trial of alemtuzumab vs. anti-thymocyte globulin induction in renal and pancreas transplantation. Clin Transplant 2008;22:41-9.	RCT, deceased or live donors	ATG vs. Alemtuzumab	45	9 (20%)	NR	8 (18%)	NR	43 (96%)	NR
								30 (94%)
			32	0 (0%)		5 (16%)		p = NS
				p = 0.007		p = NS
Hernandez et al. 2007¹⁸18 Hernández D, Miquel R, Porrini E, Fernández A, González-Posada JM, Hortal L, et al. Randomized controlled study comparing reduced calcineurin inhibitors exposure versus standard cyclosporine-based immunosuppression. Transplantation 2007;84:706-14. PMID: 17893603 DOI:http://dx.doi.org/10.1097/01.tp.0000282872.17024.b7 http://dx.doi.org/10.1097/01.tp.00002828...	RCT,deceased donors	ATG + Cyclosporine + Azathioprine vs. Basiliximab + Cyclosporine + MMF vs. Basiliximab + Tacrolimus + MMFBasiliximabe + Tacrolimus + MMF	80	12 (15%)	NR	22 (27.5%)	80 (100%)	73 (91%)	NR
							79 (98.7%)	72 (90%)
			80	11 (13.8%)		26 (32.5%)	78 (97.5%)	65 (82%)
			80	13 (16.3%)		32 (40%)
				p = NS
Thomas et al. 2007¹⁶16 Thomas PG, Woodside KJ, Lappin JA, Vaidya S, Rajaraman S, Gugliuzza KK. Alemtuzumab (Campath 1H) induction with tacrolimus monotherapy is safe for high immunological risk renal transplantation. Transplantation 2007;83:1509-12. PMID: 17565326 DOI:http://dx.doi.org/10.1097/01.tp.0000263344.53000.a1 http://dx.doi.org/10.1097/01.tp.00002633...	RCT,deceased donors	Alemtuzumab + Tacrolimus Tacrolimus vs. ATG + Tacrolimus + MMF + steroids	11	2 (18.2%)	NR	NR	11 (100%)	9 (85.7%)	1 (9%)
							7 (87.5%)	7 (87.5%)	2 (25%)
			10	3 (37.5%)				p = NS
Goggins et al. 2003⁶6 Goggins WC, Pascual MA, Powelson JA, Magee C, Tolkoff-Rubin N, Farrell ML, et al. A prospective, randomized, clinical trial of intraoperative versus postoperative Thymoglobulin in adult cadaveric renal transplant recipients. Transplantation 2003;76:798-802. PMID: 14501856 DOI:http://dx.doi.org/10.1097/01.TP.0000081042.67285.91 http://dx.doi.org/10.1097/01.TP.00000810...	RCT,deceased donors	ATG IO vs. ATG PO	27	1 (3.6%)	NR	4 (14.8%)	27 (100%)	27 (100%)	NR
							31 (100%)	31 (100%)
			31	5 (16%)		11 (35.5%)
				p = 0.11		p < 0.05
Lebranchu et al. 2002⁷7 Lebranchu Y, Bridoux F, Büchler M, Le Meur Y, Etienne I, Toupance O, et al. Immunoprophylaxis with basiliximab compared with antithymocyte globulin in renal transplant patients receiving MMF-containing triple therapy. Am J Transplant 2002;2:48-56. DOI: http://dx.doi.org/10.1034/j.1600-6143.2002.020109.x http://dx.doi.org/10.1034/j.1600-6143.20...	RCT,deceased donors	Basiliximab + Cyclosporine vs. ATG + Cyclosporine	50	4 (8%)	NR	9 (18%)	49 (98%)	47 (94%)	2 (4%)
							50 (100%)	48 (96%)	0
			50	4 (8%)		11 (22%)
Charpentier et al. 2003¹⁴14 Charpentier B, Rostaing L, Berthoux F, Lang P, Civati G, Touraine JL, et al. A three-arm study comparing immediate tacrolimus therapy with antithymocyte globulin induction therapy followed by tacrolimus or cyclosporine A in adult renal transplant recipients. Transplantation 2003;75:844-51. DOI: http://dx.doi.org/10.1097/01.TP.0000056635.59888.EF http://dx.doi.org/10.1097/01.TP.00000566...	RCTdeceased donors	Tacrolimus vs. ATG + Tacrolimus vs. ATG + Cyclosporine	185	47 (25.4%)	NR	NR	180 (97%)	172 (93.2%)	10 (5.4%)
				28 (15.1%)			183 (98.4%)	177 (95.2%)	7 (3.76%)
			186	39 (21.2%)			179 (97%)	167 (90.8%)	16 (8.69%)
				p = 0.004					p = 0.23
			184
Thibaudin et al. 1998¹⁵15 Thibaudin D, Alamartine E, de Filippis JP, Diab N, Laurent B, Berthoux F. Advantage of antithymocyte globulin induction in sensitized kidney recipients: a randomized prospective study comparing induction with and without antithymocyte globulin. Nephrol Dial Transplant 1998;13:711-5. PMID:9550651	RCT, deceased and live donors	RCT, deceased and live donors	42	27 (64%)	NR	14 (33%)	NR	32 (76%)	12 (28.5%)
				18 (38%)				42 (89%)	5 (10.63%)
			47	p = 0.02		13 (28%)		p = 0.04
						p = NS
Kyllonen et al. 2007¹²12 Kyllonen LE, Eklund BH, Pesonen EJ, Salmela KT. Single bolus antithymocyte globulin versus basiliximab induction in kidney transplantation with cyclosporine triple immunosuppression: efficacy and safety. Transplantation 2007;84:75-82. PMID: 17627241 DOI:http://dx.doi.org/10.1097/01.tp.0000268084.64888.f3 http://dx.doi.org/10.1097/01.tp.00002680...	RCT,deceased donors	ATG vs. Basiliximab vs. Immunosuppression ^* * Cyclosporine + azathioprine and steroids. Farney et al. 20085 looked into renal transplant data only.	53	6 (11.3%)	NR	3 (5.7%)	53 (100%)	52 (98.1%)	1 (1.88%)
				0 (0%)			58 (100%)	56 (96.6%)	1 (1.72%)
			58	NR		14 (24.1%)	42 (95.4%)	41 (93.2%)	4 (9.09%)
			44		7 (15.9%)
					p < 0.025
Soulillou et al. 1990⁹9 Soulillou JP, Cantarovich D, Le Mauff B, Giral M, Robillard N, Hourmant M, et al. Randomized controlled trial of a monoclonal antibody against the interleukin-2 receptor (33B3.1) as compared with rabbit antithymocyte globulin for prophylaxis against rejection of renal allografts. N Engl J Med 1990;322:1175-82. PMID: 2157982 DOI: http://dx.doi.org/10.1056/NEJM199004263221702 http://dx.doi.org/10.1056/NEJM1990042632...	RCT,deceased donors	ATG vs. 33B3.1	50	5 (10%)	15 (30%)	NR	48 (96%)	42 (85%)	8 (16%)
				7 (14.5%)			48 (96%)	42 (85%)	7 (14%)
			50	p = NS	16 (32%)
Shidban et al. 2003¹⁷17 Shidban H, Sabawi M, Puhawan M, Aswad S, Mendez RG, Mendez R. A prospective, randomized, phase IV comparative trial of Thymoglobulin(r) versus Simulect(r) for the prevention of delayed graft function and acute allograft rejection in renal transplant recipients. Am J Transplant 2003;3:352.	RCT,deceased donors	ATG vs. Basiliximab	50	4 (8%)	NR	22 (44%)	NR	NR	NR
				3 (12%)
			25	p = NS		19 (76%)
						p = 0.01
Tullius et al. 2003⁶⁶66 Tullius SG, Pratschke J, Strobelt V, Kahl A, Reinke P, May G, et al. ATG versus basiliximab induction therapy in renal allograft recipients receiving a dual immunosuppressive regimen: one-year results. Transplant Proc 2003;35:2100-1. DOI: http://dx.doi.org/10.1016/S0041-1345(03)00679-1 http://dx.doi.org/10.1016/S0041-1345(03)...	RCT,deceased donors	ATG vs. Basiliximab	62	22 (35%)	NR	NR	62 (100%)	NR	2 (3.22%)
	RCT,deceased donors	ATG vs. Basiliximab	62	20 (32%) p = NS			58 (93.5%)		6 (9.6%)

	Comparison	N	Rejection reversal rate
Hoitsma et al. 1982³¹31 Hoitsma AJ, Reekers P, Kreeftenberg JG, van Lier HJ, Capel PJ, Koene RA. Treatment of acute rejection of cadaveric renal allografts with rabbit antithymocyte globulin. Transplantation 1982;33:12-6. PMID: 7039017 DOI: http://dx.doi.org/10.1097/00007890-198201000-00003 http://dx.doi.org/10.1097/00007890-19820...	ATG (4 mg/kg per day and additional doses of 2-7 mg/kg)^ Dose adjusted based on T cell counts (50-150/mm3). vs. steroids	20	18 (90%)
		20	15 (75%)
Hilbrands et al.1996³³33 Hilbrands LB, Hoitsma AJ, Koene RA. Methylpredenisolone versus ATG as initial treatment for acute rejections after renal transplantation [abstract of European Dialysis and Transplant Association-European Renal Association (ERA-EDTA)]. Nephrol Dial Transplant 1996;11:1675.	ATG (200 mg in alternate days for ten days) vs. methylprednisolone	19	16 (84%)
		17	9 (53%)
Theodorakis et al. 1998³²32 Theodorakis J, Schneeberger H, Illner WD, Stangl M, Zanker B, Land W. Aggressive treatment of the first acute rejection episode using first-line anti-lymphocytic preparation reduces further acute rejection episodes after human kidney transplantation. Transpl Int 1998;11:S86-9. DOI:http://dx.doi.org/10.1111/j.1432-2277.1998.tb01203.x http://dx.doi.org/10.1111/j.1432-2277.19...	ATG (4 mg/kg per day for seven days) vs .methylprednisolone	25	NR^* * No difference in severity of acute renal failure between groups on first episode of acute rejection. Reduced occurrence seen in second and third episodes of rejection favoring ATG.
	ATG (4 mg/kg per day for seven days) vs .methylprednisolone	25
Baldi et al. 2000²²22 Baldi A, Malaise J, Mourad M, Squifflet JP. A prospective randomized study comparing poly-ATG to mono-OKT3 clonal antibodies for the first rejection therapy after kidney transplantation: long-term results. Transplant Proc 2000;32:429-31. PMID: 10715467 DOI: http://dx.doi.org/10.1016/S0041-1345(00)00838-1 http://dx.doi.org/10.1016/S0041-1345(00)...	ATG (4 mg/kg per day for ten days) vs. OKT3	28	21 (75%)
		28	14 (50%)
			p = 0.05

	Comparison	N	Rejection reversal rate	Graft survival rate (30-90 days)	Recurrent rejection rate (90 days)
Gaber et al. 1998/	ATG 7-14 days (1.5 mg/kg/day) vs. Atgam	82	72 (88%)	77 (94%)	14 (17%)
Tesi et al. 1997/	ATG 7-14 days (1.5 mg/kg/day) vs. Atgam	81	61 (76%)	73 (90%)	29 (36%)
Schroeder et al. 1999³⁴34 Gaber AO, First MR, Tesi RJ, Gaston RS, Mendez R, Mulloy LL, et al. Results of the double-blind, randomized, multicenter, phase III clinical trial of Thymoglobulin versus Atgam in the treatment of acute graft rejection episodes after renal transplantation. Transplantation 1998;66:29-37. PMID:9679818 DOI: http://dx.doi.org/10.1097/00007890-199807150-00005 http://dx.doi.org/10.1097/00007890-19980... 35 Tesi RJ, Kano JM, Horn HR, Schroeder T. Thymoglobulin reverses acute renal allograft rejection better than ATGAM--a double-blinded randomized clinical trial. Transplant Proc 1997;29:21S-23S. PMID: 9366922 DOI: http://dx.doi.org/10.1016/S0041-1345(97)80005-X http://dx.doi.org/10.1016/S0041-1345(97)... ^-³⁶36 Schroeder TJ, Moore LW, Gaber LW, Gaber AO, First MR. The US multicenter double-blind, randomized, phase III trial of thymoglobulin versus atgam in the treatment of acute graft rejection episodes following renal transplantation: rationale for study design. Transplant Proc 1999;31:1S-6S. DOI:http://dx.doi.org/10.1016/S0041-1345(99)00092-5 http://dx.doi.org/10.1016/S0041-1345(99)...			p = 0.027	p = 0.17	p = 0.011
Mariat et al. 1998³⁷37 Mariat C, Alamartine E, Diab N, de Filippis JP, Laurent B, Berthoux F. A randomized prospective study comparing low-dose OKT3 to low-dose ATG for the treatment of acute steroid-resistant rejection episodes in kidney transplant recipients. Transpl Int 1998;11:231-6.	ATG	31	97%	1 (3%)	28%
	< 40 kg = 25 mg/day	29	87%	3 (10%)	38%
	40 - 75Kg = 50 mg/day	29	87%	3 (10%)	38%
	> 75 kg = 75 mg/day vs. OKT3		p = NS	p = NS	p = NS
Midtvedt et al. 2003³⁸38 Midtvedt K, Fauchald P, Lien B, Hartmann A, Albrechtsen D, Bjerkely BL, et al. Individualized T cell monitored administration of ATG versus OKT3 in steroid-resistant kidney graft rejection. Clin Transplant 2003;17:69-74. DOI: http://dx.doi.org/10.1034/j.1399-0012.2003.02105.x http://dx.doi.org/10.1034/j.1399-0012.20...	ATG	27	20 (74%)	26 (96.2%)	12 (44%)
	D1 (2 mg/kg) administered again 1 mg/kg if needed vs. OKT3	28	22 (78.5%)	26 (92.8%)	14 (50%)
			p = NS	p = NS	p = NS

	N	Treatment	Leucopenia(approx.1month)	Cytomegalovirus(infection)	Tumor
Ciancio et al. 2010⁶⁴64 Ciancio G, Gaynor JJ, Roth D, Kupin W, Hanson L, Tueros L, et al. Randomized trial of thymoglobulin versus alemtuzumab (with lower dose maintenance immunosuppression) versus daclizumab in living donor renal transplantation. Transplant Proc 2010;42:3503-6. PMID: 21094804 DOI:http://dx.doi.org/10.1016/j.transproceed.2010.08.045 http://dx.doi.org/10.1016/j.transproceed...	13	ATG	0 (0%)	0 (0%)	0 (0%)
	13	Alemtuzumab	6 (46.2%)	0 (0%)	1 (769%)
	12	Daclizumab	0 (0%)	0 (0%)	0 (0%)
			(p = 0.0002)
Brennan et al. 1999²¹21 Brennan DC, Flavin K, Lowell JA, Howard TK, Shenoy S, Burgess S, et al. A randomized, double-blinded comparison of Thymoglobulin versus Atgam for induction immunosuppressive therapy in adult renal transplant recipients. Transplantation 1999;67:1011-8. PMID: 10221486 DOI:http://dx.doi.org/10.1097/00007890-199904150-00013 http://dx.doi.org/10.1097/00007890-19990...	48	ATG	27 (56%)	6 (12.5%)	0 (0%)
	24	Atgam	1 (4%)	8 (33%)	1 (4%)
			p = NS	p = 0.056
Brennan et al. 2006¹³13 Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D; Thymoglobulin Induction Study Group. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 2006;355:1967-77. DOI: http://dx.doi.org/10.1056/NEJMoa060068 http://dx.doi.org/10.1056/NEJMoa060068...	141	ATG	47 (33.3%)	11 (78%)	5 (3.5%)
	137	Basiliximab	20 (14.6%)	24 (175%)	1 (0.7%)
			p < 0.001	p = 0.02	p = 0.21
Noëlet al. 2009⁸8 Noël C, Abramowicz D, Durand D, Mourad G, Lang P, Kessler M, et al. Daclizumab versus antithymocyte globulin in high-immunological-risk renal transplant recipients. J Am Soc Nephrol 2009;20:1385-92. DOI: http://dx.doi.org/10.1681/ASN.2008101037 http://dx.doi.org/10.1681/ASN.2008101037...	113	ATG	9 (796%)	21 (18.6%)	1 (0.9%)
	114	Daclizumab	5 (4.38%)	12 (10.5%)	0 (0%)
			p = 0.36	p = 0.093	p = NS
Mourad et al. 2004²³23 Mourad G, Rostaing L, Legendre C, Garrigue V, Thervet E, Durand D. Sequential protocols using basiliximab versus antithymocyte globulins in renal-transplant patients receiving mycophenolate mofetil and steroids. Transplantation 2004;78:584-90. PMID: 15446319 DOI:http://dx.doi.org/10.1097/01.TP.0000129812.68794.CC http://dx.doi.org/10.1097/01.TP.00001298...	53	ATG	27 (51%)	22 (41.5%)	NR
	52	Basiliximab	10 (19.2%)	11 (21.2%)
			p = 0.0007	p = 0.025
Abou-Ayache et al. 2008²⁶26 Abou-Ayache R, Büchler M, Lepogamp P, Westeel PF, Le Meur Y, Etienne I, et al. CMV infections after two doses of daclizumab versus thymoglobulin in renal transplant patients receiving mycophenolate mofetil, steroids and delayed cyclosporine A. Nephrol Dial Transplant 2008;23:2024-32. DOI: http://dx.doi.org/10.1093/ndt/gfm873 http://dx.doi.org/10.1093/ndt/gfm873...	55	ATG	NR	19 (68%)	0 (0%)
	54	Daclizumab		18 (83%)	0 (0%)
Ciancio et al. 2005/2008²⁷27 Ciancio G, Burke GW, Gaynor JJ, Carreno MR, Cirocco RE, Mathew JM, et al. A randomized trial of three renal transplant induction antibodies: early comparison of tacrolimus, mycophenolate mofetil, and steroid dosing, and newer immune-monitoring. Transplantation 2005;80:457-65. PMID: 16123718 DOI: http://dx.doi.org/10.1097/01.tp.0000165847.05787.08 http://dx.doi.org/10.1097/01.tp.00001658... ^,⁶⁵65 Ciancio G, Burke GW, Gaynor JJ, Roth D, Kupin W, Rosen A, et al. A randomized trial of thymoglobulin vs. alemtuzumab (with lower dose maintenance immunosuppression) vs. daclizumab in renal transplantation at 24 months of follow-up. Clin Transplant 2008;22:200-10. DOI:http://dx.doi.org/10.1111/j.1399-0012.2007.00774.x http://dx.doi.org/10.1111/j.1399-0012.20...	30	ATG	NR	1 (3.33%)	0 (0%)
	30	Alemtuzumab		2 (6.66%)	0 (0%)
	30	Daclizumabe		0 (0%)	1 (3.33%)
Khosroshahi et al. 2008¹¹11 Khosroshahi HT, Tubbs RS, Shoja MM, Ghafari A, Noshad H, Ardalan MR. Effect of prophylaxis with low-dose anti-thymocyte globulin on prevention of acute kidney allograft rejection. Transplant Proc 2008;40:137-9. PMID: 18261569 DOI: http://dx.doi.org/10.1016/j.transproceed.2007.12.016 http://dx.doi.org/10.1016/j.transproceed...	37	Immunosuppression ^# # Cyclosporine + mycophenolate mofetil or azathioprine and prednisone;	NS	NR	NR
	31	Immunosuppression ^# # Cyclosporine + mycophenolate mofetil or azathioprine and prednisone;
	31	+ ATG
Farney et al. 2008⁵5 Farney A, Sundberg A, Moore P, Hartmann E, Rogers J, Doares W, et al. A randomized trial of alemtuzumab vs. anti-thymocyte globulin induction in renal and pancreas transplantation. Clin Transplant 2008;22:41-9.	45	ATG	NR	2 (4.44%)	NR
	32	Alemtuzumab		1 (3.12%)
				p = NS
Hernandez et al. 2007¹⁸18 Hernández D, Miquel R, Porrini E, Fernández A, González-Posada JM, Hortal L, et al. Randomized controlled study comparing reduced calcineurin inhibitors exposure versus standard cyclosporine-based immunosuppression. Transplantation 2007;84:706-14. PMID: 17893603 DOI:http://dx.doi.org/10.1097/01.tp.0000282872.17024.b7 http://dx.doi.org/10.1097/01.tp.00002828...	80	ATG + Cyclosporine + Azathioprine	NR	33 (41%)	3 (3.75%)
	80	Basiliximab + Cyclosporine + MMF		16 (20%)	2 (2.5%)
	80	Basiliximab + Tacrolimus + MMF		20 (25%)	2 (2.5%)
				p = 0.008
Thomas et al. 2007¹⁶16 Thomas PG, Woodside KJ, Lappin JA, Vaidya S, Rajaraman S, Gugliuzza KK. Alemtuzumab (Campath 1H) induction with tacrolimus monotherapy is safe for high immunological risk renal transplantation. Transplantation 2007;83:1509-12. PMID: 17565326 DOI:http://dx.doi.org/10.1097/01.tp.0000263344.53000.a1 http://dx.doi.org/10.1097/01.tp.00002633...			p < 0.05
	11	Alemtuzumab + Tacrolimus	in favor of	NR	0 (0%)
			Alemtuzumab
	10	ATG + Tacrolimus + MMF + steroids			0 (0%)
Goggins et al. 2003⁶6 Goggins WC, Pascual MA, Powelson JA, Magee C, Tolkoff-Rubin N, Farrell ML, et al. A prospective, randomized, clinical trial of intraoperative versus postoperative Thymoglobulin in adult cadaveric renal transplant recipients. Transplantation 2003;76:798-802. PMID: 14501856 DOI:http://dx.doi.org/10.1097/01.TP.0000081042.67285.91 http://dx.doi.org/10.1097/01.TP.00000810...	27	ATG IO	NR	1 (3.7%)	NR
	31	ATG PO		2 (6.5%)
				p = NS
Lebranchu et al. 2002⁷7 Lebranchu Y, Bridoux F, Büchler M, Le Meur Y, Etienne I, Toupance O, et al. Immunoprophylaxis with basiliximab compared with antithymocyte globulin in renal transplant patients receiving MMF-containing triple therapy. Am J Transplant 2002;2:48-56. DOI: http://dx.doi.org/10.1034/j.1600-6143.2002.020109.x http://dx.doi.org/10.1034/j.1600-6143.20...	50	Basiliximab + cyclosporine	0 (0%)	6 (12%)	0 (0%)
	50	ATG + cyclosporine	5 (10%)	19 (38%)	0 (0%)
			p < 0.03	p = 0.005
Charpentier et al. 2003¹⁴14 Charpentier B, Rostaing L, Berthoux F, Lang P, Civati G, Touraine JL, et al. A three-arm study comparing immediate tacrolimus therapy with antithymocyte globulin induction therapy followed by tacrolimus or cyclosporine A in adult renal transplant recipients. Transplantation 2003;75:844-51. DOI: http://dx.doi.org/10.1097/01.TP.0000056635.59888.EF http://dx.doi.org/10.1097/01.TP.00000566...	185	Tacrolimus	16 (8.6%)	29 (15.7%)	1 (0.54%)
	186	ATG +	72 (38.7%)	45 (24.2%)	2 (1.07%)
	184	Tacrolimus	64 (34.8%)	52 (28.3%)	4 (2.17%)
		ATG + cyclosporine	p < 0.001	p = 0.012
Thibaudin et al. 1998¹⁵15 Thibaudin D, Alamartine E, de Filippis JP, Diab N, Laurent B, Berthoux F. Advantage of antithymocyte globulin induction in sensitized kidney recipients: a randomized prospective study comparing induction with and without antithymocyte globulin. Nephrol Dial Transplant 1998;13:711-5. PMID:9550651	42	Immunosuppression ^* * Cyclosporine + azathioprine and steroids.	7 (17%)	17 (40%)	NR
	47	Immunosuppression ^* * Cyclosporine + azathioprine and steroids. + ATG	20 (43%)	28 (59%)
			p = 0.007	p = NS
Kyllonen et al. 2007¹²12 Kyllonen LE, Eklund BH, Pesonen EJ, Salmela KT. Single bolus antithymocyte globulin versus basiliximab induction in kidney transplantation with cyclosporine triple immunosuppression: efficacy and safety. Transplantation 2007;84:75-82. PMID: 17627241 DOI:http://dx.doi.org/10.1097/01.tp.0000268084.64888.f3 http://dx.doi.org/10.1097/01.tp.00002680...	53	ATG vs. Basiliximab vs. Immunosuppression^* * Cyclosporine + azathioprine and steroids.	NR	9 (17%)	2 (3.77%)
	58			9 (16%)	0 (0%)
	44			5 (11%)	1 (2.27%)
				p = NS	p = NS
Soulillou et al. 1990⁹9 Soulillou JP, Cantarovich D, Le Mauff B, Giral M, Robillard N, Hourmant M, et al. Randomized controlled trial of a monoclonal antibody against the interleukin-2 receptor (33B3.1) as compared with rabbit antithymocyte globulin for prophylaxis against rejection of renal allografts. N Engl J Med 1990;322:1175-82. PMID: 2157982 DOI: http://dx.doi.org/10.1056/NEJM199004263221702 http://dx.doi.org/10.1056/NEJM1990042632...	50	ATG vs. 33B3.1	> in the ATG arm	9 (18%)	NR
	50			10 (20%)
			p < 0.005
Theodorakis et al. 1998³²32 Theodorakis J, Schneeberger H, Illner WD, Stangl M, Zanker B, Land W. Aggressive treatment of the first acute rejection episode using first-line anti-lymphocytic preparation reduces further acute rejection episodes after human kidney transplantation. Transpl Int 1998;11:S86-9. DOI:http://dx.doi.org/10.1111/j.1432-2277.1998.tb01203.x http://dx.doi.org/10.1111/j.1432-2277.19...	25	ATG vs. methylprednisolone	NR	NS	NR
	25
Baldiet al. 2000²²22 Baldi A, Malaise J, Mourad M, Squifflet JP. A prospective randomized study comparing poly-ATG to mono-OKT3 clonal antibodies for the first rejection therapy after kidney transplantation: long-term results. Transplant Proc 2000;32:429-31. PMID: 10715467 DOI: http://dx.doi.org/10.1016/S0041-1345(00)00838-1 http://dx.doi.org/10.1016/S0041-1345(00)...	28	ATG vs. OKT3	4 (14.2%)	2 (71%)	2 (714%)
	28		3 (10.7%)	3 (10.7%)	0 (0%)
			p = NS	p = NS
Mariat et al. 1998³⁷37 Mariat C, Alamartine E, Diab N, de Filippis JP, Laurent B, Berthoux F. A randomized prospective study comparing low-dose OKT3 to low-dose ATG for the treatment of acute steroid-resistant rejection episodes in kidney transplant recipients. Transpl Int 1998;11:231-6.	31	ATG vs. OKT3	NR	12 (39%)	0 (0%)
	29			13 (45%)	2 (7%)
Midtvedt et al. 2003³⁸38 Midtvedt K, Fauchald P, Lien B, Hartmann A, Albrechtsen D, Bjerkely BL, et al. Individualized T cell monitored administration of ATG versus OKT3 in steroid-resistant kidney graft rejection. Clin Transplant 2003;17:69-74. DOI: http://dx.doi.org/10.1034/j.1399-0012.2003.02105.x http://dx.doi.org/10.1034/j.1399-0012.20...	27	ATG vs. OKT3	NR	14 (51.8%)	NR
	28			11 (39.2%)
				p = NS
Hoitsma et al. 1982³¹31 Hoitsma AJ, Reekers P, Kreeftenberg JG, van Lier HJ, Capel PJ, Koene RA. Treatment of acute rejection of cadaveric renal allografts with rabbit antithymocyte globulin. Transplantation 1982;33:12-6. PMID: 7039017 DOI: http://dx.doi.org/10.1097/00007890-198201000-00003 http://dx.doi.org/10.1097/00007890-19820...	20	ATG vs. steroids	NR	NS	NR
	20
Tullius et al. 2003⁶⁶66 Tullius SG, Pratschke J, Strobelt V, Kahl A, Reinke P, May G, et al. ATG versus basiliximab induction therapy in renal allograft recipients receiving a dual immunosuppressive regimen: one-year results. Transplant Proc 2003;35:2100-1. DOI: http://dx.doi.org/10.1016/S0041-1345(03)00679-1 http://dx.doi.org/10.1016/S0041-1345(03)...	62	ATG vs. Basiliximab	NR	7 (11.3%)	NR
	62			2 (3.22%)
				p = NS

	Route of infusion	Days of infusion	Time of first anti-thymocyte globulin infusion	Dose mg/kg/day (total ATG dose)
Ciancio et al. 2010⁶⁴64 Ciancio G, Gaynor JJ, Roth D, Kupin W, Hanson L, Tueros L, et al. Randomized trial of thymoglobulin versus alemtuzumab (with lower dose maintenance immunosuppression) versus daclizumab in living donor renal transplantation. Transplant Proc 2010;42:3503-6. PMID: 21094804 DOI:http://dx.doi.org/10.1016/j.transproceed.2010.08.045 http://dx.doi.org/10.1016/j.transproceed...	NR	D0 to D7	After surgery	1 mg/kg/day (7 doses)
Brennan et al. 1999²¹21 Brennan DC, Flavin K, Lowell JA, Howard TK, Shenoy S, Burgess S, et al. A randomized, double-blinded comparison of Thymoglobulin versus Atgam for induction immunosuppressive therapy in adult renal transplant recipients. Transplantation 1999;67:1011-8. PMID: 10221486 DOI:http://dx.doi.org/10.1097/00007890-199904150-00013 http://dx.doi.org/10.1097/00007890-19990...	NR	D0 to D6	During surgery (before graft reperfusion)	1.5 mg/kg/day (6 doses)
Brennan et al. 2006¹³13 Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D; Thymoglobulin Induction Study Group. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 2006;355:1967-77. DOI: http://dx.doi.org/10.1056/NEJMoa060068 http://dx.doi.org/10.1056/NEJMoa060068...	NR	D0 to D4	During surgery (before graft reperfusion)	1.5 mg/kg/day (75mg/kg)
Noëlet al. 2009⁸8 Noël C, Abramowicz D, Durand D, Mourad G, Lang P, Kessler M, et al. Daclizumab versus antithymocyte globulin in high-immunological-risk renal transplant recipients. J Am Soc Nephrol 2009;20:1385-92. DOI: http://dx.doi.org/10.1681/ASN.2008101037 http://dx.doi.org/10.1681/ASN.2008101037...	Central catheter	D0 to D7	During surgery (before graft reperfusion)	1.25 mg/kg/day
Mourad et al. 2004²³23 Mourad G, Rostaing L, Legendre C, Garrigue V, Thervet E, Durand D. Sequential protocols using basiliximab versus antithymocyte globulins in renal-transplant patients receiving mycophenolate mofetil and steroids. Transplantation 2004;78:584-90. PMID: 15446319 DOI:http://dx.doi.org/10.1097/01.TP.0000129812.68794.CC http://dx.doi.org/10.1097/01.TP.00001298...	NR	NR	NR	1 mg/kg/day DO and D1 and adjusted based on CD3 + (mean of 5.4 infusions)
Abou-Ayache et al. 2008²⁶26 Abou-Ayache R, Büchler M, Lepogamp P, Westeel PF, Le Meur Y, Etienne I, et al. CMV infections after two doses of daclizumab versus thymoglobulin in renal transplant patients receiving mycophenolate mofetil, steroids and delayed cyclosporine A. Nephrol Dial Transplant 2008;23:2024-32. DOI: http://dx.doi.org/10.1093/ndt/gfm873 http://dx.doi.org/10.1093/ndt/gfm873...	NR	D0 to D9	After surgery	1-1.5mg/kg/day (< 9 doses, mean of 6.5 days)
Ciancio et al. 2005/2008²⁷27 Ciancio G, Burke GW, Gaynor JJ, Carreno MR, Cirocco RE, Mathew JM, et al. A randomized trial of three renal transplant induction antibodies: early comparison of tacrolimus, mycophenolate mofetil, and steroid dosing, and newer immune-monitoring. Transplantation 2005;80:457-65. PMID: 16123718 DOI: http://dx.doi.org/10.1097/01.tp.0000165847.05787.08 http://dx.doi.org/10.1097/01.tp.00001658... ^,⁶⁵65 Ciancio G, Burke GW, Gaynor JJ, Roth D, Kupin W, Rosen A, et al. A randomized trial of thymoglobulin vs. alemtuzumab (with lower dose maintenance immunosuppression) vs. daclizumab in renal transplantation at 24 months of follow-up. Clin Transplant 2008;22:200-10. DOI:http://dx.doi.org/10.1111/j.1399-0012.2007.00774.x http://dx.doi.org/10.1111/j.1399-0012.20...	NR	7 days	After surgery	1 mg/kg/day (x 7 doses)
Khosroshahi et al. 2008¹¹11 Khosroshahi HT, Tubbs RS, Shoja MM, Ghafari A, Noshad H, Ardalan MR. Effect of prophylaxis with low-dose anti-thymocyte globulin on prevention of acute kidney allograft rejection. Transplant Proc 2008;40:137-9. PMID: 18261569 DOI: http://dx.doi.org/10.1016/j.transproceed.2007.12.016 http://dx.doi.org/10.1016/j.transproceed...	NR	D0	Before surgery (12h hours before the procedure)	4-5 mg/kg
Farney et al. 2008⁵5 Farney A, Sundberg A, Moore P, Hartmann E, Rogers J, Doares W, et al. A randomized trial of alemtuzumab vs. anti-thymocyte globulin induction in renal and pancreas transplantation. Clin Transplant 2008;22:41-9.	Central catheter	D0, D2, D4, D6, etc.	During surgery	1.5 mg/kg/day (< 7 doses + 5 mg/kg)
Hernandez et al. 2007¹⁸18 Hernández D, Miquel R, Porrini E, Fernández A, González-Posada JM, Hortal L, et al. Randomized controlled study comparing reduced calcineurin inhibitors exposure versus standard cyclosporine-based immunosuppression. Transplantation 2007;84:706-14. PMID: 17893603 DOI:http://dx.doi.org/10.1097/01.tp.0000282872.17024.b7 http://dx.doi.org/10.1097/01.tp.00002828...	NR	7 days	NR	1-1.5 mg/kg/day (7 days)
Thomas et al. 2007¹⁶16 Thomas PG, Woodside KJ, Lappin JA, Vaidya S, Rajaraman S, Gugliuzza KK. Alemtuzumab (Campath 1H) induction with tacrolimus monotherapy is safe for high immunological risk renal transplantation. Transplantation 2007;83:1509-12. PMID: 17565326 DOI:http://dx.doi.org/10.1097/01.tp.0000263344.53000.a1 http://dx.doi.org/10.1097/01.tp.00002633...	NR	D0 to D4	Before surgery	1.5 mg/kg/day (x4)
Goggins et al. 2003⁶6 Goggins WC, Pascual MA, Powelson JA, Magee C, Tolkoff-Rubin N, Farrell ML, et al. A prospective, randomized, clinical trial of intraoperative versus postoperative Thymoglobulin in adult cadaveric renal transplant recipients. Transplantation 2003;76:798-802. PMID: 14501856 DOI:http://dx.doi.org/10.1097/01.TP.0000081042.67285.91 http://dx.doi.org/10.1097/01.TP.00000810...	Mostly peripheral catheters	D0 to D6	During or after surgery	1 mg/kg (< 6 doses)
Lebranchu et al. 2002⁷7 Lebranchu Y, Bridoux F, Büchler M, Le Meur Y, Etienne I, Toupance O, et al. Immunoprophylaxis with basiliximab compared with antithymocyte globulin in renal transplant patients receiving MMF-containing triple therapy. Am J Transplant 2002;2:48-56. DOI: http://dx.doi.org/10.1034/j.1600-6143.2002.020109.x http://dx.doi.org/10.1034/j.1600-6143.20...	AV fistula or central catheter	D1 to D10	After surgery (24 hours after transplantation)	1-1.5 mg/kg/day (6-10 days; no more than 1O days)
Charpentier et al. 2003¹⁴14 Charpentier B, Rostaing L, Berthoux F, Lang P, Civati G, Touraine JL, et al. A three-arm study comparing immediate tacrolimus therapy with antithymocyte globulin induction therapy followed by tacrolimus or cyclosporine A in adult renal transplant recipients. Transplantation 2003;75:844-51. DOI: http://dx.doi.org/10.1097/01.TP.0000056635.59888.EF http://dx.doi.org/10.1097/01.TP.00000566...	NR	D1 to D10	After surgery (< 12 hours after transplantation)	1.25 mg/kg and adjusted based on clinical status
Thibaudin et al. 1998¹⁵15 Thibaudin D, Alamartine E, de Filippis JP, Diab N, Laurent B, Berthoux F. Advantage of antithymocyte globulin induction in sensitized kidney recipients: a randomized prospective study comparing induction with and without antithymocyte globulin. Nephrol Dial Transplant 1998;13:711-5. PMID:9550651	NR	D0 to D10	During surgery (before graft reperfusion)	1.25 mg/kg/day DO and adjusted based on CD 2+ and CD3+
Kyllonen et al. 2007¹²12 Kyllonen LE, Eklund BH, Pesonen EJ, Salmela KT. Single bolus antithymocyte globulin versus basiliximab induction in kidney transplantation with cyclosporine triple immunosuppression: efficacy and safety. Transplantation 2007;84:75-82. PMID: 17627241 DOI:http://dx.doi.org/10.1097/01.tp.0000268084.64888.f3 http://dx.doi.org/10.1097/01.tp.00002680...	NR	D0	During surgery (before graft reperfusion)	9 mg/kg single dose
Soulillou et al. 1990⁹9 Soulillou JP, Cantarovich D, Le Mauff B, Giral M, Robillard N, Hourmant M, et al. Randomized controlled trial of a monoclonal antibody against the interleukin-2 receptor (33B3.1) as compared with rabbit antithymocyte globulin for prophylaxis against rejection of renal allografts. N Engl J Med 1990;322:1175-82. PMID: 2157982 DOI: http://dx.doi.org/10.1056/NEJM199004263221702 http://dx.doi.org/10.1056/NEJM1990042632...	AV fistula or central catheter	D0to D14	After surgery	1.5 mg/kg/day (maximum of 2.5 mg/kg)
Shidban et al. 2003¹⁷17 Shidban H, Sabawi M, Puhawan M, Aswad S, Mendez RG, Mendez R. A prospective, randomized, phase IV comparative trial of Thymoglobulin(r) versus Simulect(r) for the prevention of delayed graft function and acute allograft rejection in renal transplant recipients. Am J Transplant 2003;3:352.	NR	D0 to D5	NR	1.5 mg/kg/day for 5 days under 100 mg/day);
Tullius et al. 2003⁶⁶66 Tullius SG, Pratschke J, Strobelt V, Kahl A, Reinke P, May G, et al. ATG versus basiliximab induction therapy in renal allograft recipients receiving a dual immunosuppressive regimen: one-year results. Transplant Proc 2003;35:2100-1. DOI: http://dx.doi.org/10.1016/S0041-1345(03)00679-1 http://dx.doi.org/10.1016/S0041-1345(03)...	Tullius	NR	NR	9 mg/kg perioperatorio

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[1] Correspondence to: Maria Cristina Ribeiro de Castro. Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Rua Dr. Jose Rodrigues Alves Sobrinho, nº 150, ap 222, Edif. Miró. São Paulo, SP. CEP: 05466-040. E-mail: mcrc@usp.br Tel: (11) 3672-7628. Sanofi.

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Use of Thymoglobulin® (antithymocyte immunoglobulin) in renal transplantation: practical guide

Abstract

Use of Thymoglobulin^® (antithymocyte immunoglobulin) in renal transplantation: practical guide