The impact of induction on survival after lung transplantation: An analysis of the International Society for Heart and Lung Transplantation Registry

Background: The use of induction immunosuppression after lung transplantation remains controversial. In this study, we examined the impact of induction on survival after lung transplantation. Methods: We performed a retrospective cohort study of 3970 adult lung transplant recipients reported to the ISHLT Registry. We divided the cohort into three groups based on the use of induction: none, interleukin-2 receptor antagonists (IL-2 RA), and polyclonal antithymocyte globulins (ATG). We estimated graft survival using the Kaplan-Meier method and constructed a multivariable Cox proportional hazards model to examine the impact of induction on graft survival in the context of other variables. Result: During the study period, 2249 patients received no induction, 1124 received IL-2 RA, and 597 received ATG. Four years after transplantation, recipients treated with IL-2 RA had better graft survival (64%) than those treated with ATG (60%) and those who did not receive induction (57%; log rank p = 0.0067). This survival advantage persisted in the multivariable model for single and bilateral recipients treated with IL-2 RA compared to those who did not receive induction (RR=0.82, p = 0.007). Similarly, bilateral recipients treated with ATG had a survival advantage over bilateral recipients who did not receive induction (RR=0.78, p = 0.043), but single lung recipients treated with ATG did not have a survival advantage over single lung recipients who did not receive induction (RR = 1.06, p = 0.58). Conclusions: Induction with lL-2 RA for single and bilateral lung recipients and induction with ATG for bilateral recipients are associated with a survival benefit, independent of other variables that might impact survival.