One center's experience with antithymocyte globulin treatment for acute rejection in renal transplantation

Antithymocyte globulin (ATG) is a polyclonal antibody used in renal transplantation for prevention and treatment of acute rejection. In this study we have presented the outcomes of 23 cases treated with ATG due to steroid-resistant acute rejection episodes in 17 male and 6 female recipients. Sixteen transplantations were performed from cadaver donors and the other 7 from living-related donors. The mean recipient age was 31.9 +/- 9 years and the mean donor age was 56.3 +/- 10.8 years. ATG treatment was administered in doses of 3-5 mg/kg/d for 10 or 14 days. All patients received the same premedication before the ATG treatment; we did not encounter any ATG-related side effects. ATG doses were adjusted according to the T-lymphocyte levels. All recipients were followed up for infectious complications, for graft function, and for immunologic parameters of CD3 levels, CD4 levels, CD3/CD4 ratios, lymphocyte, and polymorphonuclear leukocyte numbers. According to the Banff criteria introduced in 1997, 4 patients displayed humoral rejection: 3 had type 3; 5 had type 2; and 11 had type 1 acute rejection episodes. Nine patients developed infectious complication during the follow-up. Three had pulmonary aspergillosis; 2 had cytomegalovirus infection; and 4 had bacterial infections. One patient who experienced aspergillosis died with a functioning graft, and the remaining 8 patients were treated successfully. Graft function improved in 19 (83%) cases. The other 4 patients returned to hemodialysis. Mean creatinine levels decreased from 4 +/- 1.7 to 2.1 +/- 0.2 mg/dL. We did not observe any relationship between the immunologic parameters and infectious complications. In conclusion, although ATG is a powerful drug to treat steroid-resistant acute rejection episodes, there was no precise way to monitor the intensity of immunosuppression to prevent infectious complications.