Thymoglobulin Induction Therapy in Kidney Transplant Patients Receiving Organs Donated after Cardiac Death in China: A Real-World Patient-Level Pooled Analysis of the T-DCD and Start-DCD Studies

Background: Thymoglobulin is used in kidney transplantation as an induction therapy to prevent acute rejections; however, studies and data to support thymoglobulin induction therapy in Chinese patients undergoing kidney transplant with donation after cardiac death (DCD) kidneys remain unclear. Therefore, we investigated the clinical outcomes of thymoglobulin induction therapy in recipients of DCD kidney transplant in real-world clinical practice. Methods: This pooled analysis from the T-DCD and START-DCD studies was conducted to investigate acute rejection (AR), biopsy-proven AR (BPAR), delayed graft function (DGF), and graft and patient survival at 6 months in patients undergoing DCD kidney transplantation in the pooled population, in subgroups receiving thymoglobulin doses of <4 mg/kg and ≥4 mg/kg, and in subgroups receiving thymoglobulin doses of <1.5 mg/kg, 1.5 mg/kg to 4 mg/kg, and ≥4 mg/kg. Possible risk factors for AR, BPAR, DGF, graft survival, and patient survival were investigated as well. Results: A total of 458 patients were included in this study. The incidence of AR within 6 months was 8% (n = 10) in patients receiving <4 mg/kg of thymoglobulin and 10.5% (n = 35) in those receiving ≥4 mg/kg. The dose-dependent incidence of BPAR was 3.1% in patients receiving a thymoglobulin dose <1.5 mg/kg, 2.3% in those receiving 1.5 to 4 mg/kg, and 1.6% in those receiving ≥4 mg/kg. In these 3 subgroups, a statistically significant reduction in DGF incidence (P = .023) was observed in 21.9%, 15.9%, and 7.2% of patients, respectively. The overall graft survival and patient survival rates at 6 months were 98% and 99.56%, respectively. The possible risk factors for AR were donor or recipient age, those for DGF were baseline creatinine and dosage, and those for graft survival were donor body mass index, warm ischemia time, thymoglobulin dosage, and donor history of cardiopulmonary resuscitation. Conclusion: Based on a pooled analysis of the T-DCD and START-DCD data in Chinese patients, treatment with thymoglobulin as an induction therapy has shown greater dose-dependent protection against DGF within 6 months after kidney transplantation. The higher thymoglobulin dose did not prolong the duration or reduce the incidence of AR and BPAR and showed no significant effect on graft survival or patient survival within 6 months of transplantation.