Very early meningoencephalopathy associated with the intraoperative use of OKT3 in renal retransplant

Abstract

Muromonab CD3 (murine monoclonal antibody towards the cluster of differentiation 3 antigen; OKT3) is a murine IgG 2a monoclonal antibody from the OKT series that specifically reacts with the epsilon chain of the CD3 molecular complex on the surface of circulating T lymphocytes. OKT3 can be used as a treatment for acute allograft rejection episodes and as "rescue" therapy for steroid-resistant allograft rejection [1][2][3][4][5][6][7] . OKT3 can also be used during the perioperative period as induction therapy in sequential immunosuppressive regimens. Recently, OKT3 has elicited renewed interest due to its capacity to induce immune tolerance. This aspect will probably lead to the revaluation of OKT3 role for organ transplants 1 . We report a patient who received intraoperative inductive OKT3 in renal retransplant to improve graft viability. The patient developed a very early aseptic OKT3-related meningoencephalopathy that complicated her management during the immediate postoperative period. We were unable to find in literature such early onset of meningoencephalopathy associated with use of OKT3. CASEA 26-year old female with end-stage renal failure of undefined cause was admitted for cadaveric renal retransplant. She was on hemodialysis since 1990 and underwent to an unsuccessful renal transplantation in 1993.Short before surgery hemodialysis was optimized in order to minimize CRS. Surgery started 19:00. Midazolam (15 mg) was used as anesthetic premedication. General anesthesia was induced with etomidate (0.2 mg/kg), sulfentanil (1 mg/kg) in bolus followed by atracurium (0.5 mg/kg) that was repeated every 30 minutes. She received epidural analgesia with bipuvocaine plus dimorphine. Anesthesia was maintained with O 2 /N 2 O [1:1] and isofluorane (concentration up to 1%) under controlled mechanical ventilation. Patient was monitored according with ASA recommendations. Inductive immunosuppressive therapy (sequential therapy) was applied through intravenous intraoperative use of 500 mg of methylprednisolone, followed by 5 mg OKT3 one hour later. These drugs were used before allograft perfusion. The surgery ended at about 23:00 h and all surgical and anesthetic procedures occurred without abnormalities. At about 01:15 h the patient presented fever (37.6ºC). During the next hours her body temperature ranged from 37.6 to 38.5ºC, while arterial pressure was stable, and arterial oxygen saturation ranged from 97% to100%, with O 2 administered through a Venturi mask. Since recovery from anesthesia was quite delayed, blood tests were ordered and she was admitted into the intensive care unit, where she was seen by a neurologist.Upon this first neurological evaluation she showed response only to vigorous physical stimuli. She presented nuchal rigidity and had miotic pupils, but normal oculocephalic reflexes. Generalized hypertonia was evident and deep tendon reflexes were briskly symmetrical. Bilateral Babinski's sign was present. At this time urea was 94 mg/dL, creatinine was 5.5 mg/dL, hemoglobin was 9.4 g/dL, hematocrit wa...