Efficacy and Safety of Extended-Duration Inpatient-to-Outpatient Rabbit Antithymocyte Globulin Induction in De Novo Kidney Transplant Recipients

Abstract

In an effort to reduce length of stay (LOS) in kidney transplant recipients otherwise ready for discharge, we developed a protocol to extend rabbit antithymocyte globulin (rATG) induction therapy into the outpatient setting through peripheral dose administration. A retrospective review of outpatient rATG group (n=185) that received the first two rATG doses inpatient and subsequent doses outpatient was used, compared with concurrently transplanted patients who received all doses of rATG as an inpatient (n=99). The outpatient group received more rATG (cumulative mg/kg induction) than the inpatient-only group (median [range], 4.8 mg/kg [3.2-10.0] vs. 4.4 mg/kg [2.8-8.6]; P<0.01). Outpatient usage avoided 246 hospital days that would have been required had rATG been administered in the inpatient setting. The incidences of perioperative leukopenia and thrombocytopenia were lower in the outpatient rATG group versus inpatient-only group (5% vs. 21%, P<0.01, and 2% vs. 9%, P<0.01, respectively) but were similar by 3 months. The outpatient rATG group experienced shorter hospitalization LOS compared with the inpatient-only group (median LOS [range], 4 [2-11] vs. 5 [3-20] days; P<0.01) and lower 30-day readmission rates (30% vs. 42%, P=0.03). At 6 months, there were no differences in incidences of biopsy-proven rejection episodes. When implemented selectively among less complicated kidney transplant recipients, delayed extension of rATG into the outpatient setting was associated with LOS reduction and attendant cost saving without either increasing readmission rate or compromising short-term safety and efficacy.