Introduction: Induction and maintenance immunosuppression protocols that incorporate steroid avoidance or withdrawal are increasingly common (1, 2). Few pediatric studies have evaluated Basiliximab with a rapid steroid withdrawal protocol (3, 4). We present a single center retrospective study comparing Basiliximab with rapid steroid withdrawal to Thymoglobulin induction and associated graft outcomes.
Methods: All patients who underwent kidney transplantation at the Children’s Hospital at Montefiore from August 2009-February 2022, were available for inclusion. A total of 78 patients were identified and followed post transplantation. Descriptive analysis of the study sample was performed comparing two induction therapy groups: Basiliximab + RSW and Thymoglobulin. Patients with pre-transplant PRA ≥20% or pre-formed donor specific antibodies (DSA) received thymoglobulin as per center transplant protocol. Steroid switch was defined as patients who underwent rapid steroid withdrawal post-transplant and later switched to steroid use. Analysis of transplant outcomes included time to biopsy, rejection, de novo DSA, eGFR at 1 year and most recent eGFR post-transplant, ≥50% decline in eGFR from 1-year post-transplant to most recent eGFR, and allograft loss.
Results: A total of 78 patients were identified and followed for a mean follow-up time of 4.7±3.6 years (Figure 1). Of the 78 patients, 31 (39.7%) received Basiliximab with RSW and 47 (60.3%) patients received Thymoglobulin induction. Four patients in the Thymoglobulin induction group underwent RSW. Among both groups with RSW, 9 patients underwent steroid switch (75% in Thymoglobulin group and 16.4% in the Basiliximab group). Patients in the thymoglobulin induction group had a significantly shorter time to clinically indicated biopsy compared to Basiliximab+RSW group (p=0.03) (Figure 2). A higher proportion of patients in the Thymoglobulin group developed de novo DSA when compared to the Basiliximab+RSW group, although this was not statistically significant (73 vs. 51.7%). In both groups there was an immunodominance of HLA Class II antibodies amongst those with DSA. There was no significant difference in time to rejection or frequency of rejection (Thymoglobulin 27.7% vs Basiliximab + RSW 25.8%), eGFR at 1-year post-transplant, most recent eGFR, and allograft loss between groups. However, 29% of patients who received Thymoglobulin had ≥50% decline in rate of eGFR compared to 4.8% in the Basiliximab+RSW group (p=0.03).


Conclusion: We conclude that the use of Basiliximab with rapid-steroid withdrawal may be safe in select pediatric kidney transplant recipients.