Serum sickness following rabbit antithymocyte-globulin induction in a liver transplant recipient: Case report and literature review

Abstract

Thymoglobulinா (Genzyme, Cambridge, MA) is an antithymocyte globulin preparation used for induction immunosuppression therapy in solid organ transplantation. It is being utilized with increasing frequency in orthotopic liver transplantation (OLT) in an effort to minimize or delay the use of calcineurin inhibitors due to their inherent nephrotoxicity. Experience with thymoglobulin in OLT remains limited. We report a case of serum sickness in a patient who received thymoglobulin following OLT. The patient experienced intermittent fevers, polyarthralgia, and acute renal failure 9 days after completion of thymoglobulin administration. The patient's symptoms resolved rapidly and completely with a course of intravenous steroids. We review a set of diagnostic criteria for serum sickness and emphasize the importance of early recognition of the process. Early treatment of serum sickness with steroids or plasmapheresis is highly effective and can reduce unnecessary morbidity from this unusual sequela of induction immunosuppression with antithymocyte globulin. Liver Transpl 13:647-650, 2007.Received October 12, 2006; accepted December 12, 2006. Immunosuppressive drug regimens after orthotopic liver transplantation (OLT) attempt to maximize graft acceptance by the host while minimizing the suppression of systemic immunity and systemic side effects.

Review on immunosuppression in liver transplantation

“…Premedication with antihi stamines and acetaminophen is recommended as rare severe cardiovascular reactions and anaphylaxis have been reported [36] . Serum sickness may develop following rATG administration [37] . More common adverse side effects of AGT are the result of severe cytokine release syndrome induced by the agent.…”

Antibodies to anti-thymocyte globulin in aplastic anemia patients have a negative impact on hematopoietic SCT

“…8,9 Previous exposure to ATG predisposes to the development of Abs against ATG, and to serum sickness. 10,11 IgG Anti-ATG leads to a faster clearance and lower ATG levels may lead to either rejection or acute GVHD, as we know from transplanted patients not receiving ATG. 12 In SAA patients, serum sickness is reported to be associated with poorer outcome.…”

Transient Low-Dose Methotrexate Induces Tolerance to Murine Anti-Thymocyte Globulin and Together They Promote Long-Term Allograft Survival

“…Rapamycin showed only a modest delay of graft survival when administered with mATG (Ref. 19; J. Williams, unpublished observations), whereas the combination of mATG with CTLA4Ig displayed a significant benefit, with skin grafts surviving to day 50 (16). This survival benefit of the mATG and CLTA4Ig combination was attributed to an enhancement of T regulatory cells through blocking the CD28/B7 costimulatory pathways, which we did not observe in our studies with mATG and methotrexate.…”

“…ATG, however, is not generally administered repeatedly over extended periods of time, because Thymoglobulin-treated transplant recipients have sporadically been reported to experience serum sickness, acute renal failure, or cardiovascular reactions. These reactions have been linked to anti-drug Abs (17)(18)(19)(20)(21). We explored whether low-dose methotrexate can reduce anti-ATG Ab responses in nonclinical studies using a murine version of Thymoglobulin, mATG.…”