The impact of induction therapy on the risk of posttransplant lymphoproliferative disorder in adult kidney transplant recipients with donor-recipient serological Epstein-Barr virus mismatch

Post-transplant lymphoproliferative disorder (PTLD) poses a significant concern in Epstein-Barr Virus (EBV)-negative patients transplanted from EBV-positive donors (EBV R-/D+). Previous studies investigating the association between different induction agents and PTLD in these patients have yielded conflicting results. Using the Organ Procurement and Transplant Network (OPTN) database, we identified EBV R-/D+ patients >18 years of age who underwent kidney-alone transplant between 2016 and 2022 and compared the risk of PTLD with rabbit antithymocyte globulin (ATG), basiliximab and alemtuzumab inductions. Among the 6,620 patients included, 64.0% received ATG, 23.4% received basiliximab, and 12.6% received alemtuzumab. The overall incidence of PTLD was 2.5% over a median follow-up period of 2.9 years. Multivariable analysis demonstrated that the risk of PTLD was significantly higher with ATG and alemtuzumab, in comparison to basiliximab (adjusted subdistribution hazard ratio [aSHR] = 1.98, 95% confidence interval [CI] 1.29-3.04, P = 0.002 for ATG and aSHR = 1.80, 95% CI 1.04-3.11, P = 0.04 for alemtuzumab). However, PTLD risk was comparable between ATG and alemtuzumab inductions (aSHR = 1.13, 95% CI 0.72-1.77, P = 0.61). Therefore, the risk of PTLD must be taken into consideration when selecting the most appropriate induction therapy for this patient population.