Use of Induction Therapy Post Heart Transplantation - Clinical Practice Recommendations Based on Systematic Review and Network Meta-Analysis of Evidence.

In patients undergoing heart transplantation (HTx), induction therapy (IT) provides early intense immunosuppression. Whether to use IT, and the choice of optimal regimen remains controversial. We undertook a systematic review and network meta-analysis to assess outcomes following the use of IT agents, that informed a clinical practice guideline on the utility of contemporary agents: Thymoglobulin and Basiliximab. We recruited an international, multidisciplinary panel, inclusive of 3 patient partners, 5 cardiologists, 1 surgeon, 1 nurse practitioner, 1 pharmacist, and 4 methodologists. We used the GRADE framework summarize findings and develop recommendations. To develop internationally applicable recommendations, our panel took a global perspective. The panel considered balance between benefits and harms, quality of evidence, and patient's values and preferences, to make recommendations for or against the use of Thymoglobulin or Basiliximab. The panel focused on the following outcomes: all-cause mortality, cellular rejection (requiring treatment), infection, renal dysfunction, and malignancy. The review provided low- or, in most cases, very low-quality evidence of either benefit or harm of the two agents, leaving the effects of the interventions uncertain. The panel judged that with low or very low-quality evidence providing no compelling suggestion of benefit, the majority of patients would be reluctant to receive an intervention with possible serious adverse effects. Therefore, our review resulted in weak recommendations as follows: Recommendation #1: In adult HTx recipients, we suggest against the routine use of Basiliximab, as compared to no induction therapy. Recommendation #2: In adult HTx recipients, we suggest against the routine use of Thymoglobulin, as compared to no induction therapy. Recommendation #3: In adult HTx recipients for whom induction therapy is deemed desirable, we suggest using Thymoglobulin over Basiliximab. Our panel made weak recommendations against the routine use of IT agents. In select patients in whom shared decision-making leads to a decision to choose IT, the panel favored the use of Thymoglobulin over Basiliximab. Additional studies are needed to identify patient subgroups that may derive benefit from IT. [ABSTRACT FROM AUTHOR]