Induction therapy in kidney transplant recipients: A consensus statement of Indian Society of Organ Transplantation

Kidney transplantation (KT) accounts for nearly three-fourths of organ transplants in India, with living donors contributing to 82% of cases. Induction immunosuppression is essential to optimize initial immunosuppression, reduce acute rejections, and enable tailored use of maintenance agents. Rabbit anti-thymocyte globulin (rATG) and interleukin-2 receptor anatagonists (IL-2RA/IL-2RBs) are the most widely used induction therapies. However, data on induction practices across India are limited. To evaluate induction immunosuppression practices across KT centers in India and establish a consensus for different subsets of KT recipients. A nationwide online survey was conducted by the Indian Society of Organ Transplantation (ISOT) among its members (400 KT centers). Responses were analyzed to assess induction practices across diverse donor types, age groups, and immunological risk profiles. Heterogeneity in practices prompted consensus building using a modified Delphi process. Literature review and expert panel discussions (April 2024) were followed by structured voting, and 16 consensus statements were finalized. Of 400 centers approached, 254 participated. rATG was the most commonly used induction therapy, followed by IL-2RBs; alemtuzumab was least used. Significant heterogeneity was observed in type, dose, and duration of induction therapy. Consensus recommendations were framed: rATG for high immunological risk recipients and deceased donor KTs; IL-2RB or low-dose rATG for low immunological risk; rituximab in ABO-incompatible KTs; and tailoring based on age, diabetes, donor type, infection risk, and affordability. This first ISOT consensus provides 16 India-specific statements on induction therapy in KT. It emphasizes risk-stratified, evidence-informed, and context-appropriate induction strategies, supporting standardization of care across the country.