Severe Intraoperative Anaphylaxis Related to Thymoglobulin during Living Donor Kidney Transplantation

Abstract

Anaphylaxis secondary to thymoglobulin (anti-thymocyte globulin) is a rare condition that can be life threatening. Thymoglobulin is a rabbit-derived T-cell depleting polyclonal immunoglobulin. It is commonly used for induction immunosuppression and/or for treatment of acute rejection in renal transplantation. We report a case of a living kidney transplant recipient who developed intraoperative anaphylactic shock secondary to thymoglobulin. The patient had a history of pet rabbit exposure. This case report highlights the importance of prompt identification and management of intraoperative anaphylaxis, which is key to a successful outcome. Induction immunosuppression selection based on patient characteristics is important. Communication between the anesthesia team and surgeons played a key role in stopping the donor surgery.

Use of antithymocyte globulin (rabbit) in a patient with known alpha-gal syndrome undergoing allogenic stem cell transplantation

“…7 Rabbit antithymocyte globulin has been implicated in anaphylactic allergic reactions, primarily in relation to IgE-mediated reactions against rabbit antigens and also to excipients of the drug formulation itself. [17][18][19] No reports of allergic reactions to rATG related to AGS are currently available.…”

New polyclonal antibodies, inhibit selectively tumor growth and invasion and synergize with immune checkpoint inhibitors

“…A direct consequence is that Neu5Gc and Gal epitopes are excluded from “self-tolerance” and that natural anti-Neu5Gc and anti-Gal antibodies are present in humans ( 54 ). Infusion of antibodies from animal origin elicits strong immunogenicity, with side effects ranging from mild fever or skin rashes to more serious SSD ( 55 , 56 ) or anaphylactic shock ( 57 , 58 ). To circumvent these drawbacks and allow clinical evaluation of pAb in oncology, we generated GH-pAb, already shown to present an acceptable safety and tolerability profiles in humans ( 59 , 60 ).…”

A case report: anaphylaxis to cefazolin during renal transplant surgery

“…Intraoperative anaphylaxis is a medical emergency that poses significant challenges to the anesthesiologist, especially in transplant surgery [ 4 – 6 ]. During general anesthesia, 60 percent of all anaphylactic reactions are triggered by neuromuscular blocking agents, followed by latex (20 percent), and antibiotics (15 percent) [ 7 ].…”

“…When anaphylaxis is considered intraoperatively, it is the anesthesiologist’s responsibility to manage the clinical situation with supportive therapies and help facilitate the diagnostic workup. If the diagnosis of anaphylaxis is not clear due to a non-traditional presentation, it is recommended to send a tryptase level to confirm or rule out the diagnosis [ 2 , 4 , 6 ]. Tryptase levels peak one and half hours after the onset of anaphylaxis, but levels drawn up to 3 h after symptom onset can support the diagnosis [ 4 , 10 ].…”

“…If the diagnosis of anaphylaxis is not clear due to a non-traditional presentation, it is recommended to send a tryptase level to confirm or rule out the diagnosis [ 2 , 4 , 6 ]. Tryptase levels peak one and half hours after the onset of anaphylaxis, but levels drawn up to 3 h after symptom onset can support the diagnosis [ 4 , 10 ]. Additionally, the anesthesiologist should ensure that the patient is counseled regarding the event and a referral placed to see an allergist for skin testing 1 month following the event [ 6 ].…”