Safety and Feasibility of Outpatient Rabbit Antithymocyte Globulin Induction Therapy Administration in Kidney Transplant Recipients

Varga, Alexandra N.; Johnson, David G.; Sawinski, Deirdre; Lim, Mary Ann; Bloom, Roy D.; Abt, Peter L.; Goral, Simin; Bleicher, Melissa; Levine, Matthew H.; Naji, Ali; Nazarian, Susanna M.; Porrett, Paige M.; Trofe‐Clark, Jennifer

doi:10.1002/phar.2116

Cited by 2 publications

(4 citation statements)

References 21 publications

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“…Some providers have asked about incorporating G-CSF administration to assist with WBC count recovery during administration of T-cell depleting therapy such as r-ATG, though there is no organ transplant literature to support this practice. We do not advocate for this practice at our center given the availability to delay r-ATG administration to the outpatient setting, which allows for recovery from cytopenia-related adverse events between doses without compromising efficacy 24. A previous study by Stevens et al25 suggested that failure to appropriately adjust VGCV dosing based on renal function may contribute to the risk of leukopenia in kidney transplant recipients.…”

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confidence: 99%

“…About half of our patients had their prednisone dose slightly increased concomitant with decreases in their antimetabolite. We do not advocate for this practice at our center given the availability to delay r-ATG administration to the outpatient setting, which allows for recovery from cytopenia-related adverse events between doses without compromising efficacy 24. Notably, 97.2% of our study population received at least one dose of r-ATG for induction immunosuppression.…”

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confidence: 99%

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Single‐center, real‐world experience with granulocyte colony‐stimulating factor for management of leukopenia following kidney transplantation

Hamel

Kuo

Sawinski

et al. 2019

Clinical Transplantation

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Background Leukopenia is a frequent complication following kidney transplantation. Granulocyte colony‐stimulating factor (G‐CSF) has been used to accelerate white blood cell (WBC) count recovery; however, published experience in kidney transplantation is limited. Methods We retrospectively reviewed our kidney transplant recipients from January 2012 to September 2016 with a G‐CSF order to evaluate leukopenia management (defined as WBC <3000 cells/μL). Results Thirty‐six recipients were included. On average, G‐CSF treatment began at 98 ± 38 days. At G‐CSF initiation, mean WBC count was 1240 ± 420 cells/μL and absolute neutrophil count (ANC) was 653 ± 368 cells/μL. Mean G‐CSF dose was 4.6 ± 1.2 mcg/kg/dose (total 11.8 ± 9.0 mcg/kg), 77.8% of recipients were prescribed G‐CSF as outpatients, and overall, median time to WBC count recovery was 9 (IQR 4‐14) days. Changes in immunosuppression and prophylaxis regimens for leukopenia were also common. Within 1 month following leukopenia onset, no patients experienced acute rejection and 5 (14%) developed infection requiring hospitalization or opportunistic infection. Conclusion In kidney recipients with leukopenia, G‐CSF may be helpful to achieve WBC count recovery in addition to changes in immunosuppression and prophylaxis medications. Prospective, randomized data are still needed to determine optimal G‐CSF dosing in this population.

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confidence: 99%

Single‐center, real‐world experience with granulocyte colony‐stimulating factor for management of leukopenia following kidney transplantation

Hamel

Kuo

Sawinski

et al. 2019

Clinical Transplantation

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“…33,[41][42][43] Compared with central administration, peripheral administration of rATG offers several advantages by avoiding central catheter placement and associated complications and facilitating outpatient administration. 26,44,45 Peripheral administration of rATG has been shown to be safe and effective when administered in the ambulatory setting without increased rates of readmissions and resulting in significant reduction in hospital length of stay. 42,45 Infusion time is the major limitation to this strategy.…”

Section: Peripheral and Outpatient Ratg Administrationmentioning

confidence: 99%

“…26,44,45 Peripheral administration of rATG has been shown to be safe and effective when administered in the ambulatory setting without increased rates of readmissions and resulting in significant reduction in hospital length of stay. 42,45 Infusion time is the major limitation to this strategy. While outpatient administration has not been studied in the setting of rejection treatment, the benefits in this population would theoretically be more substantial, given the higher cumulative dose for this indication and lack of need for inpatient surgical recovery.…”

Section: Peripheral and Outpatient Ratg Administrationmentioning

confidence: 99%

A call for transplant stewardship: The need for expanded evidence‐based evaluation of induction and biologic‐based cost‐saving strategies in kidney transplantation and beyond

Jorgenson

Descourouez

Brady

et al. 2021

Clinical Transplantation

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Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higherquality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.

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Safety and Feasibility of Outpatient Rabbit Antithymocyte Globulin Induction Therapy Administration in Kidney Transplant Recipients

Abstract: Outpatient administration of rATG is feasible, safe, and did not increase readmissions in the period directly following administration. The findings of this analysis support our continued use of the outpatient rATG protocol at our institution.

Cited by 2 publications

References 21 publications

Single‐center, real‐world experience with granulocyte colony‐stimulating factor for management of leukopenia following kidney transplantation

Single‐center, real‐world experience with granulocyte colony‐stimulating factor for management of leukopenia following kidney transplantation

A call for transplant stewardship: The need for expanded evidence‐based evaluation of induction and biologic‐based cost‐saving strategies in kidney transplantation and beyond

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