Induction with antithymocyte globulin is associated with decreased mortality and PTLD in pediatric liver transplantation: a UNOS data analysis

Methods: A retrospective analysis of the United Network for Organ Sharing database was performed for pediatric liver transplant cases between 2010 and 2024. Graft failure, acute rejection, recipient mortality, post-transplant lymphoproliferative disorder (PTLD) and cytomegalovirus (CMV), hospitalization, and post-operative length of stay were collected. Rates of each outcome were compared for the most common induction (antithymocyte globulin [ATG], basiliximab/daclizumab, or no induction regimen [induction without depleting/nondepleting agents]) and maintenance therapies (calcineurin inhibitors [CI] alone, CI + steroids, CI + mycophenolate mofetil [MMF], or CI + MMF + steroids).

Results: Of 6369 pediatric liver transplant recipients who met inclusion criteria, 1563 (24.5%) underwent induction with basiliximab/daclizumab, 639 (10.0%) with anti-thymocyte globulin, and 4167 (65.4%) with no induction. For maintenance therapy, 2854 (46.0%) patients received CI + steroids, 2309 (37.2%) CI + MMF + steroids, 695 (11.2%) CI alone, and 351 (5.7%) CI + MMF. ATG was associated with decreased risk of PTLD compared to no induction (HR = 2.028, p = 0.028) and basiliximab/daclizumab (HR = 2.158, p = 0.020). ATG was associated with lower mortality (HR = 0.634, p = 0.041). Acute rejection was decreased with no induction (hazard ratio [HR] = 0.820, p = 0.011). No other differences in graft failure, CMV, hospitalization, or length of initial stay were present between induction or maintenance therapies.

Conclusions: Induction with ATG is associated with decreased mortality and PTLD, though it is also associated with an increased risk of organ rejection. These results may support its use in the optimal induction regimen for pediatric liver transplantation.