Antibody induction in renal transplantation has increased to over 80%. Rabbit anti-thymocyte globulin (rATG) is the most commonly used agent. Hypotension, rash, dyspnea with rATG occurs in 10-30%. We describe desensitization to rATG in a patient allergic to all commonly used induction agents.

43yo Caucasian male with ESRD (IgAN) had a deceased donor kidney transplant (DDKTx) 2yrs previously. Arterial thrombus and allograft loss occurred due to rATG related hypotension. Subsequent testing revealed a positive allergen test for rATG. 7 months later he received a DDKTx 1A/2B/1DR HLA mismatch, CMV D+/R-, peak PRA 80%. ATGAM 15mg/kg was used for induction. 5 hours into the infusion he had chills, dyspnea and palpitations. Urine output declined and creatinine increased. Tacrolimus was started on POD1 with levels >10ng/ml achieved. Alemtuzumab was attempted but he developed a similar allergic reaction. Methylprednisolone 250mg IV/d x 3 doses and TPE x3 were given to reduce the chance of rejection. An allograft biopsy on POD 4 revealed ATN and no rejection. Given his high-risk and lack of depletion induction we performed rATG desensitization. He was pretreated with IV solumedrol 1mg/kg at 12hr, 7hr and 1hr prior to rATG initiation. IV Benadryl and IV Famotidine were given 12 and 1hrs prior to rATG infusion. Total dose of 4mg/kg of rATG (400 mg) was planned (split into 3 different concentrations 0.005mg/ml, 0.05mg/ml and 0.5mg/ml)

During the final 0.5mg/ml infusion, he had chills and shivering. Infusion was stopped. He was given IV solumedrol 100mg, Benadryl 25mg and Famotidine 20mg. He continued to have chills for the next 2hrs. Final dose of rATG received was 1.5mg/kg (150mg). He continues to have good renal function with no rejection episodes.

CITATION INFORMATION: Venkatachalam K., Malone A. Successful Transplantation in a Sensitized Patient Allergic to Commercially Available Antibody Induction Agents Am J Transplant. 2017;17 (suppl 3).

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