Antibodies | Rabbit-Derived Antithymocyte Globulin-Associated Perioperative Anaphylaxis in Renal Transplantation: A Multidisciplinary Review

This article systematically reviews the relevance of rabbit antithymocyte globulin (rATG) in inducing immunosuppression during kidney transplantation and provides an in-depth analysis of the pathophysiology, clinical manifestations, and management strategies of potential perioperative allergic reactions. Combining clinical case studies with a multidisciplinary perspective, it offers practical guidance for early identification and intervention to clinicians.

Literature Overview
This article, titled "Rabbit-Derived Antithymocyte Globulin-Associated Perioperative Anaphylaxis in Renal Transplantation: A Multidisciplinary Perspective on Pathophysiology, Clinical Presentation, and Management" and published in the journal Antibodies, reviews and summarizes allergic reactions that may occur during the induction of immunosuppression using rATG in kidney transplantation, including mechanisms, clinical manifestations, and management approaches. The entire content is well-structured and offers clinical guidance.

Background Knowledge
Induction immunosuppression during kidney transplantation is a critical strategy for preventing acute rejection, and rATG is widely used for its ability to polyclonally deplete T cells. However, because it is derived from rabbit immunoglobulins, some patients may experience severe allergic reactions due to prior rabbit allergies or cross-reactivity. This article thoroughly explores the pathophysiological mechanisms, clinical manifestations, and management approaches of rATG-related allergies, and analyzes their rare but potentially fatal risks through multiple case reports from the literature. The study also notes that traditional NIAID criteria may be insufficient for diagnosing allergic reactions in the absence of cutaneous symptoms, and the WAO criteria offer higher sensitivity for diagnosis. Additionally, it emphasizes the importance of interdisciplinary communication during surgery for rapid identification and intervention. The content is professional and information-rich.

Research Methods and Experiments
This study employs a systematic literature review approach to analyze multiple clinical cases of rATG-associated perioperative anaphylaxis and explores the pharmacological aspects of rATG, including its manufacturing process, mechanism of action, and adverse effects. By comparing the diagnostic criteria of NIAID and WAO, the study evaluates the efficiency of identifying allergic reactions under different clinical presentations. Furthermore, it analyzes the distinction between IgE-mediated anaphylaxis and non-IgE-mediated anaphylactoid reactions based on pathophysiological mechanisms, and proposes an integrated management strategy incorporating clinical manifestations and laboratory tests (e.g., serum tryptase, histamine, and urinary methylhistamine measurements).

Key Conclusions and Perspectives

• rATG is one of the most commonly used induction immunosuppressants in kidney transplantation due to its broad T cell depletion capability, offering better long-term graft survival than monoclonal antibodies.
• While rATG is generally well tolerated, it can cause acute perioperative allergic reactions, including anaphylactic shock, which may manifest atypically in some patients without cutaneous symptoms.
• Allergic reactions are primarily IgE-mediated, but non-IgE-mediated anaphylactoid reactions, such as complement activation or cytokine release syndrome (CRS), may also occur.
• Literature reports of rATG-associated allergic reactions often present as acute hypotension, bronchospasm, or cardiorespiratory distress, necessitating vigilant monitoring and prompt intervention.

Conclusion
This article provides a systematic analysis of perioperative anaphylaxis associated with rATG in kidney transplantation, underscoring the importance of early recognition and multidisciplinary management. Given the coexistence of IgE-mediated and non-IgE-mediated mechanisms, clinicians should be familiar with differential diagnosis and management protocols for various allergic responses. Intraoperative monitoring, including changes in end-tidal CO2 and blood pressure fluctuations, can serve as early warning indicators. Although such allergic reactions are rare, they can significantly impact the course and outcome of transplantation if they occur. Future research should focus on developing specific assays for sensitizing proteins in rATG to improve preoperative screening accuracy and optimize immunosuppressive protocols.

Multiple Sequence Alignment

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Multiple Sequence Alignment is used for aligning DNA and protein sequences, and visualizing the results of the sequence alignment. It aids in sequence clustering, analyzing diversity among sequences, identifying conserved regions and mutations. It includes automatic alignment tools such as ClustalW and MUSCLE, with MUSCLE incorporating clustering methods like NJ(Neighbor Joining), UPGMA(Unweighted Pair Group Method with Arithmetic Mean), and UPGMB(Unweighted Pair Group Method with Banded Mean).