Induction With and Without Antithymocyte Globulin Combined With Cyclosporine/Tacrolimus-Based Immunosuppression in Renal Transplantation: A Meta-analysis of Randomized Controlled Trials

Abstract Objective The objective of this study was to conduct a meta-analysis of randomized controlled trials (RCT) to compare the effectiveness and safety of induction with and without antithymocyte globulin (ATG) combined with cyclosporine/tacrolimus-based immunosuppression in renal transplantation. Methods Trials were identified through a computerized literature search of PubMed, EMBASE, Cochrane controlled trials register, Cochrane Renal Group Specialized Register of RCTs, and Chinese Biomedical database. Two independent reviewers assessed trials for eligibility and quality, and then extracted data. Data were extracted for patient and graft survival, acute rejection, the incidence of Banff, cytomegalovirus (CMV) infection, leukopenia, and thrombocytopenia. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence intervals (CI). Results Four RCTs (892 patients) were identified. The data showed that induction with ATG was more beneficial than no induction with ATG to reduce the incidence of chronic rejection (RR 0.70; 95% CI, 0.57–0.84) and acute rejection within 6 months (RR 0.68; 95% CI, 0.49–0.96) and at 12 months (RR 0.67; 95% CI, 0.50–0.89) as well as Banff II episodes (RR 0.53; 95% CI, 0.30–0.91), but increased the incidences of CMV infection (RR 1.61; 95% CI, 1.27–2.04) and leukopenia (RR 3.88; 95% CI, 2.80–5.38) and thrombocytopenia (RR 2.92; 95% CI, 1.77–4.04). There was no statistical difference between patient or graft survival rates at 6 and 12 months, as well as the incidences of Banff III or Banff I after transplantation. Conclusion Based on available data induction with ATG was more efficient to reduce the rate of acute rejection episodes and chronic rejection responses after renal transplantation, but was associated with increased side effects, particularly CMV infections. It is important to provide the most benefit for an individual patient.