Alemtuzumab or basiliximab: Rethinking induction choice beyond acute rejection in kidney transplantation

Table 1 Integrated comparison of induction strategies: Biological effects and long-term clinical consequences[1-5,19-26,28,30-34,42-45,53-57]

Domain	Alemtuzumab induction	Basiliximab induction
Core mechanism	Profound pan-lymphocyte depletion (T cells, B cells, NK cells, monocytes) with prolonged immune reconstitution	Selective interleukin-2 receptor blockade on activated T cells; non-depleting
Early immunological control	Very strong suppression of early cellular alloimmune responses	Adequate suppression in matched, standard-risk recipients
Acute rejection	Reduced or comparable rates in contemporary cohorts	Comparable rates in propensity-matched cohorts
Immune reconstitution trajectory	Delayed and non-physiological, driven by lymphopenia-induced proliferation and immune skewing	Preserved immune architecture with gradual return to equilibrium
Humoral alloimmunity	Higher incidence of de novo donor-specific anti-HLA antibodies associated with B-cell regenerative dynamics	Lower incidence of de novo donor-specific antibody formation
Viral susceptibility	Increased risk of cytomegalovirus and BK viremia due to impaired immune surveillance	Lower relative viral risk
Malignancy risk	Increased incidence observed with extended follow-up, reflecting impaired tumour surveillance	Lower incidence
Graft function	Inferior functional trajectory at defined time points	More stable long-term graft function
Death-censored graft loss	Higher risk in propensity-matched cohorts	Lower risk
Overall long-term balance	Early immunological gain offset by delayed biological and clinical costs	Moderated early suppression with improved long-term graft stability

Immune reconstitution refers to the quantitative and qualitative recovery of lymphocyte subsets following induction therapy. Graft function denotes estimated glomerular filtration rate-based functional trajectory over follow-up. Death-censored graft loss indicates graft failure excluding patient death with a functioning graft. NK: Natural killer; HLA: Human leukocyte antigen; BK: BK polyomavirus.