SUN-018 Exploring an affordable option for induction therapy for live donor kidney Transplantation- r-ATG (Anti thymocyte globulin) vs. low dose e-ATG Therapy in Sri Lanka

Abstract

Induction therapy in the early post-transplant period has become a universally accepted method to get better outcomes in transplantation. ATG is being used widely especially in high risk transplantation. Antithymocyte globulin (ATG) is a poly clonal antibody that is used as induction therapy to treat acute rejection, It is a mixture of non-specific anti-lymphocyte immunoglobullins targeting T cell subsets and several immune and none immune cells. There are 2 types of ATG. r-ATG (rabbit) and e-ATG (equine) in comparison to other induction therapies like basiliximab, diclizumab and newer agents like alamtuzumab. These monoclonal therapies have a good outcome in renal transplantation and have their share of side effects. Our study is to compare the 2 types of ATGs as a cost benefit in comparison to the other more expensive alternatives. We have done a comparative study on a strictly alternative basis of r ATG vs. e ATG. The outcomes of both of these immunosuppressive therapies in a study done on 157 patients in the year 2016 at a private sector hospital in sri lanka .82 patients were given e-ATG and 75 were given r-ATG, calculated according to their body weight. at induction e-ATG was given at a dose of 15mg/kg which is a smaller dose in comparison to doses used in larger centers worldwide. 1250mg of e-ATG was given in 2 divided doses on Day 0(500-750mg) and Day 3(500mg) and r-ATG 125mg in 2 divided doses on Day 0 (75mg) and Day 3 (50mg) post kidney transplantation. We measures post induction reactions, Rejection rates, CDcounts, creatinine, lymphocyte counts and cost. Post induction reactions: Vital signs were monitored for both types of ATG. It was seen that 22% of patients in both groups had fever post induction. 33% have blood pressure alterations, 30% had chills, nausea or vomiting. And only 1% had a sever anaphylactic reaction. Post Transplant Rejection: We observed that only 21% of patient developed rejection in those who were given e-ATG and 21% developed rejection in those given r-ATG. Biopsies were also done in those who had strong chemical suspicion of rejection 26% had biopsies in the e-ATG group whereas nearly 28% of the r-ATG group got biopsies done. There was no significant difference in both groups. CD COUNTS: On Day 0 and day 10 Observations for absolute CD levels were noted. there was a 13% absolute reduction in e-ATG group and 11% decrease in r-ATG group. P value was <0.05 and was statistically significant. We have used r-ATG and low dose e-ATG and found very similar rejection rates, biopsy rates and infection rates in comparison to each other and in comparison to other induction therapies. The cost of induction therapy is cut down by 400 USD (62,000 LKR) per patient If using e-ATG and cost will be 1200 USD (190,000 LKR) more if on other induction therapies like basiliximab. Therefore we recommend the use of low dose e-ATG as an alternative to r-ATG as it provides cost savings and economic advantage and has a similar clinical outcome when compared to basiliximab, alamtuzumab and dicluzumab. We feel as we come from a middle income country and cost is a major factor in our daily practice e ATG is a good alternative to newer drugs with similar outcomes.