Thymoglobulin Dosing for Induction in Kidney Transplant Recipients: A Systematic Review

Purpose of Review: Rabbit anti-thymocyte globulin (rATG) is a key agent in induction immunosuppression for kidney transplantation, yet its optimal dosing strategy remains controversial. This review evaluates recent data to assess the impact of various dosing regimens on efficacy, safety, and cost-effectiveness. Recent Findings: Lower cumulative doses of rATG may reduce infection rates and hematologic toxicity without compromising efficacy. In contrast, higher doses, while more effective at preventing rejection, are associated with an increased risk of infectious complications. Single-dose administration offers logistical and economic advantages, whereas multi-dose regimens provide sustained T-cell depletion, which may benefit high-risk recipients. Individualized dosing strategies—such as using ideal body weight—have proven effective in both obese and non-obese patients. Pediatric patients generally require lower cumulative doses. Emerging evidence supports biomarker-guided intermittent dosing to optimize drug exposure and reduce adverse effects. Summary: Although variability in existing data limits the formulation of universal guidelines, evidence supports the adoption of individualized approaches. These include immunologic risk stratification, pharmacokinetic modeling, biomarker-guided strategies, and practical dosing logistics. Future prospective studies are critical to validate and standardize these approaches, ensuring safe, effective, and economically sustainable use of rATG in kidney transplantation.