Abstract Objectives: Reducing the incidence of delayed graft function after transplant with donation after cardiac death donor renal allografts would facilitate managing recipients during their first weeks after a transplant. To reduce this incidence, in most studies, induction therapy with depleting anti-T-lymphocyte antibodies is coupled with a reduction of the dosage of the calcineurin inhibitor. The separate effect of anti-T-cell therapy on the incidence and duration of delayed graft function is therefore difficult to assess. Patients and Methods: We performed a randomized study to evaluate the effect of a single intraoperative high-dose of anti-T-lymphocyte immunoglobulin (ATG)-Fresenius (9 mg/kg body weight) on the incidence of delayed graft function. Eligible adult recipients of a first donation after cardiac death donor renal allograft were randomly assigned to ATG-Fresenius or no induction therapy. Maintenance immunosuppression consisted of tacrolimus, in an unadjusted dose, mycophenolate mofetil, and steroids. Results: The study was prematurely terminated because of a lower-than-anticipated inclusion rate. Baseline characteristics were comparable in the ATG-Fresenius group (n=28) and the control group (n=24). Twenty-two patients in the ATG-Fresenius group (79%) had delayed graft function, compared with 13 in the control group (54%; P = .06). Allograft and patient survival were comparable in both groups. Serious adverse events occurred more frequently in the ATG-Fresenius group than they did in the control group (57% vs 29%; P < .05). Conclusions: Intraoperative administration of a single high-dose of ATG-Fresenius in donation after cardiac death donor renal allograft recipients, followed by triple immunosuppression with an unadjusted tacrolimus dose, seems ineffective to reduce the incidence of delayed graft function. Moreover, this was associated with a higher rate of serious adverse events (EudraCT-number, 2007-000210-36.) Key words: Anti-T-lymphocyte immunoglobulin, Delayed graft function, Donation after cardiac death Introduction The increased waiting list for renal transplant has prompted the use of so-called “expanded criteria donors” to increase the number of renal allografts available for transplant. Donation after cardiac death (DCD) has emerged as a satisfactory option to provide renal allografts with patient and graft survival rates similar to those obtained with renal allografts from donation after brain death donors. 1 A major problem aRTICLE Effect of a Single Intraoperative High-Dose ATG-Fresenius on Delayed Graft Function in Donation After Cardiac-Death Donor Renal Allograft Recipients: A Randomized Study Martijn W. F. van den Hoogen, 1 Marcia M. L. Kho, 2 Alferso C. Abrahams, 3 Arjan D. van Zuilen, 3 Jan-Stephan Sanders, 4 Marja van Dijk, 4 Luuk B. Hilbrands, 1 Willem Weimar, 2 Andries J. Hoitsma 1 DOI: 10.6002/ect.2012.0220 Copyright © Başkent University 2013 Printed in Turkey. All Rights Reserved. From the 1 Department of Nephrology, Radboud University Nijmegen Medical Centre; the 2 Department of Nephrology, Erasmus Medical Centre Rotterdam; 3 Department of Nephrology, University Medical Centre Utrecht; and the 4 Department of Nephrology, University Medical Centre Groningen, The Netherlands Acknowledgements: This study was financially supported by Fresenius Biotech GmbH, Gräfelfing, Germany. The company had no input in study design, data collection, data analysis, and writing or editing of the manuscript. We thank Marjo van Helden and Judith Kal-van Gestel for continually monitoring the study and managing the database, and we thank Ronald Hené for his valuable comments. Corresponding author: M. W. F. van den Hoogen, Department of Nephrology 464, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6525 GA Nijmegen, The Netherlands Phone: +31 24 361 4761 Fax: +31 24 354 0022 E-mail: m.vandenhoogen@aig.umcn.nl Experimental and Clinical Transplantation (2013) 2: 134-141