Antibodies | Rabbit-Derived Antithymocyte Globulin-Associated Perioperative Anaphylaxis in Renal Transplantation: A Multidisciplinary Perspective on Pathophysiology, Clinical Presentation, and Management

This study systematically reviews the mechanisms, clinical features, and management strategies of anaphylactic reactions induced by rabbit antithymocyte globulin (rATG) during kidney transplantation. The article provides practical recommendations from a multidisciplinary perspective, which helps clinicians in early recognition and safe handling of this rare yet serious adverse event.

 

Literature Overview
The article titled "Rabbit-Derived Antithymocyte Globulin-Associated Perioperative Anaphylaxis in Renal Transplantation: A Multidisciplinary Perspective on Pathophysiology, Clinical Presentation, and Management", published in the journal Antibodies, reviews and summarizes the severe allergic reactions potentially induced by rATG in kidney transplantation and their management strategies. The article comprehensively analyzes the mechanisms, clinical manifestations, diagnostic criteria, and treatment approaches of such reactions and highlights the importance of early recognition and multidisciplinary collaboration through real clinical cases.

Background Knowledge
Rabbit antithymocyte globulin (rATG) is a polyclonal antibody widely used as an immunosuppressive induction agent before kidney transplantation, effectively reducing the incidence of acute rejection. Although it has a favorable safety profile, rATG still carries the risk of causing perioperative allergic reactions, which can be life-threatening in severe cases. The mechanisms of these reactions are primarily related to IgE-mediated anaphylaxis, although non-IgE-mediated anaphylactoid reactions have also been reported. Due to the presence of multiple comorbidities and the administration of various medications in kidney transplant patients, identifying and confirming rATG-associated allergic reactions can be challenging. This study presents a multidisciplinary approach to managing rATG-induced allergic reactions through literature review and clinical experience, aiming to improve intraoperative diagnostic accuracy and optimize treatment strategies.

 

 

Research Methods and Experiments
The article systematically reviews the mechanisms, clinical manifestations, and management strategies of rATG-associated allergic reactions through literature analysis and discusses multidisciplinary approaches using several clinical cases. The study also compares different diagnostic criteria (NIAID vs. WAO) and addresses the challenges in early recognition of allergic reactions under anesthesia.

Key Conclusions and Perspectives

• rATG is a commonly used induction immunosuppressant in kidney transplantation with excellent long-term efficacy, but it may rarely cause severe allergic reactions requiring attention.
• The mechanism of allergic reactions is primarily IgE-mediated, but may also involve mast cell/basophil degranulation through non-IgE pathways.
• Perioperative allergic reactions to rATG often manifest as hypotension, bronchospasm, and cutaneous symptoms, and must be differentiated from cytokine release syndrome and anaphylactoid reactions.
• The WAO diagnostic criteria are superior to NIAID criteria as they do not rely on cutaneous symptoms, making them more suitable for anesthetized patients.
• Immediate discontinuation of rATG, administration of intravenous epinephrine, fluid resuscitation, and mechanical ventilation if necessary are critical interventions during intraoperative allergic reactions.
• Postoperative decisions should be based on the patient’s stability, and options such as switching induction agents or postponing surgery may be considered.

Research Significance and Prospects
This study provides clinicians with a practical guide for recognizing and managing rATG-associated allergic reactions during kidney transplantation. Future research could focus on identifying the sensitizing proteins in rATG and developing safer alternative immunosuppressive agents.

 

 

Conclusion
Although rabbit antithymocyte globulin (rATG) is widely used in kidney transplantation, its associated perioperative anaphylactic reactions are rare yet potentially life-threatening. This study emphasizes the importance of early recognition, timely intervention, and multidisciplinary collaboration in managing such reactions. By summarizing multiple clinical cases, it proposes a diagnostic approach based on WAO criteria and provides practical guidance for transplant teams through intraoperative monitoring and management strategies. Additionally, the study warns that even after the allergic reaction is controlled, biphasic reactions remain a concern, necessitating extended postoperative monitoring. This review offers important insights into the selection of immunosuppressive agents and allergy risk assessment in clinical practice, ultimately enhancing drug safety in kidney transplantation.

 

Imran Gani, Usman Baig, Ahmad Mirza, Shais Jallu, and Abrar Ahad Chawdhary. Rabbit-Derived Antithymocyte Globulin-Associated Perioperative Anaphylaxis in Renal Transplantation: A Multidisciplinary Perspective on Pathophysiology, Clinical Presentation, and Management. Antibodies.