Basiliximab induction and renal recovery after liver transplantation in high-risk recipients

Introduction Basiliximab is used as a renal-sparing strategy to delay calcineurin inhibitor initiation in liver transplant recipients with pre-transplant renal impairment at risk of post-transplant acute kidney injury and progression to chronic kidney disease. However, data on long-term renal outcomes in high-risk recipients remain limited. Methods We conducted a retrospective, multicentre cohort study of adult deceased donor liver transplant recipients at two Australian transplant centres (2018 - 2022). Basiliximab was administered at clinician discretion based on pre-transplant renal function and anticipated acute kidney injury risk. Longitudinal changes in serum creatinine from baseline to day 1 peak and 3, 6, 12 and 24 months were compared between groups. Secondary outcomes included renal dysfunction resolution, post-transplant renal replacement therapy, biopsy-proven rejection, graft survival and patient survival. Results Among 405 recipients, 232 (57%) received basiliximab. Basiliximab-treated patients represented a higher-risk cohort, with a significantly higher baseline serum creatinine and Model for End-Stage Liver Disease score, and greater prevalence of hepatorenal syndrome-acute kidney injury, pre-transplant terlipressin use, vasopressor support and renal replacement therapy. Despite this, basiliximab recipients showed early and sustained improvement in adjusted serum creatinine from 3 months post-transplantation onwards and were independently more likely to achieve renal dysfunction resolution at 12- and 24-months. Adjusted serum creatinine remained unchanged in the non-basiliximab group. There were no differences in post-transplant renal replacement therapy, biopsy-proven rejection, graft survival, or patient survival between groups. Discussion By enabling a renal-sparing immunosuppression strategy, basiliximab induction facilitated sustained renal recovery post-transplant without increased rejection or graft loss in high-risk recipients.