| Summary: | Due to organ shortage, donation after circulatory death (DCD) has increased. As DCD kidney grafts have higher rates of delayed graft function (DGF), the French national protocol mandates the use of hypothermic machine perfusion and routine anti-thymocyte globulin (ATG) induction therapy. However, evidence favoring ATG over interleukin-2 receptor antagonists, such as basiliximab, remains scarce. We retrospectively analysed a single-center cohort of 158 low immunological risk patients who underwent DCD kidney transplantation between 2015 and 2023. Patients transplanted before March 2020 received ATG (n = 64), while those transplanted thereafter (during and after the COVID-19 pandemic) received basiliximab (n = 94). Baseline characteristics were comparable, except for recipient age (lower in the basiliximab group), and cold ischemia times were similar. There were no differences in primary non-function, DGF rates (17% after ATG versus 12% after basiliximab), biopsy-proven rejection, one-year renal function or graft survival. ATG was associated with prolonged EBV and BK viremia without increased complications. Hospital stays were similar, but ATG induction was 1.7 times more expensive. These findings were confirmed in an independent French multicenter cohort (n = 506). In conclusion, basiliximab appears to be a cost-effective alternative to ATG for low-immunological-risk patients receiving DCD kidney grafts, for whom ATG is not clearly indicated.
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