Transient pulmonary infiltrates during treatment with anti-thymocyte globulin

Respiratory distress syndrome caused by influenza H1N1 in a patient with a simultaneous pancreas-kidney transplantation

Adult respiratory distress syndrome is a severe respiratory failure due to noncardiogenic pulmonary edema with high mortality rates (50-70%). The most common etiology of respiratory distress is sepsis, but it may also be caused by several of the immunosuppressants prescribed in transplantation. In the last year, influenza H1N1 virus infection has become more relevant. It has shown a greater incidence among immunosuppressed patients as well as those with chronic kidney disease or diabetes mellitus. We present the case of a patient with simultaneous pancreas-kidney transplantation who presented respiratory distress after the second dose of thymoglobulin. Initially, we interpreted that the thymoglobulin was the cause, so it was replaced with basiliximab. Empirical treatment was started with 3 doses of 6-methylprednisolone (250 mg), with a favorable response. After 7 days, we received the results of the reverse-transcriptase polymerase chain reaction of a nasal smear and blood culture, which were positive for H1N1 virus. In our knowledge, this is the first reported case of a patient with simultaneous pancreas-kidney transplantation and respiratory distress secondary to H1N1 virus infection who showed a favorable response to corticosteroid therapy.

Anti-thymocyte globulin induced non-cardiogenic pulmonary edema during renal transplantation

Non-cardiogenic pulmonary edema (NCPE) is a clinical syndrome characterized by simultaneous presence of severe hypoxemia, bilateral alveolar infiltrates on chest radiograph, without evidence of left atrial hypertension/congestive heart failure/fluid overload. The diagnosis of drugrelated NCPE relies upon documented exclusion of other causes of NCPE like gastric aspiration, sepsis, trauma, negative pressure pulmonary edema. We describe a 28year-old, 50 kg male with ASA risk III posted for laparoscopic renal transplantation, who developed NCPE after 4 hours of administration of rabbit anti-human thymocyte immunoglobulin (ATG). He was successfully treated with mechanical ventilatory support and adjuvant therapy. This report emphasizes that this fatal complication may occur with use of ATG.

Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases

Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.

Acute lung injury during antithymocyte globulin therapy for aplastic anemia

The case of a 33-year-old man with aplastic anemia who experienced recurrent episodes of hypoxemia and pulmonary infiltrates during infusions of antithymocyte globulin (ATG) is described. With the use of high-dose corticosteroids, the patient's original episodes resolved, and were subsequently prevented before additional administrations of ATG. Rare reports of an association between ATG and acute lung injury are found in the literature, but this is the first report of successful steroid-supported re-exposure. Although the mechanism of ATG-related acute lung injury remains uncertain, it may be parallel to the mechanism of transfusion-related acute lung injury because the pathogenesis of the latter relies, in part, on antileukocyte antibodies. ATG-related toxicity should be included in the differential diagnosis of new, infusion-associated pulmonary infiltrates, and corticosteroids may be a useful therapeutic consideration in the management.

Treatment of refractory Wegener's granulomatosis with antithymocyte globulin (ATG): an open study in 15 patients

BACKGROUND

A subset of patients with Wegener's granulomatosis does not respond sufficiently to cyclophosphamide and glucocorticosteroids or suffers of intolerable side effects. Anecdotal data suggest that antithymocyte globulin (ATG) may be a treatment option for these patients. We now describe 15 patients treated with ATG for refractory Wegener's granulomatosis.

METHODS

Fifteen patients with histologically proven active refractory Wegener's granulomatosis (seven unresponsive to cyclophosphamide, eight intolerant) were treated with ATG by a protocol (SOLUTION protocol) designed by the European Vasculitis Study (EUVAS) Group.

RESULTS

Before ATG administration, patients had received a mean of 5.2 (range 2 to 7) different therapeutic approaches including glucocorticosteroids and cyclophosphamide in all and experimental therapies in six, without control of disease activity [2.8 (range 1 to 7) relapses during a disease duration of 63.2 (range 18 to 180) months]. Thirteen of 15 patients showed a favorable response to ATG with partial (N= 9) or complete (N= 4) remission. During a follow-up of 21.8 (range 6 to 68) months, seven patients relapsed after a mean of 8.4 (range 2 to 24) months (five minor and two major relapses). Six patients are free of relapse for 22.3 (range 7 to 64) months. Two patients died, 1 and 3 days following the first dose of ATG, due to pulmonary hemorrhage and infection (one each). Although further immunosuppressive treatment was required in all surviving patients, a less intensive regimen could be applied in 12. Beside fever and chills associated with the first gift of ATG, ATG was well tolerated, with infections being observed in five cases and serum sickness in two.

CONCLUSION

Anti-T-cell-directed treatment with ATG may be a therapeutic option for severe refractory Wegener's granulomatosis if simultaneous infections and fluid overload have been ruled out. In patients with alveolar hemorrhage, ATG should only be used under special caution.

Management of patients receiving antithymocyte globulin for aplastic anemia and myelodysplastic syndrome

Antithymocyte globulin (ATG) is used commonly in patients with severe aplastic anemia and those undergoing renal transplant. Its utility also is being explored in the treatment of myelodysplastic syndrome, conditioning regimens for hematopoietic stem cell transplant, and prophylaxis of graft-versus-host disease. As indications for ATG expand, knowledge regarding its administration and management of associated toxicities is needed. These toxicities range from life-threatening anaphylaxis associated with the infusion to flu-like symptoms that occur one to two weeks after the infusion. Adverse effects are classified according to the severity and system impacted. Mild toxicities respond to comfort measures and include fever, chills, urticarial rash, and vomiting. Moderate toxicities require acute interventions and include fluid-responsive hypotension, nonischemic chest pain, and reversible oxygen desaturation. Severe toxicities require intensive support and include those refractory to earlier intervention. Management of these toxicities usually is limited to fluid resuscitation and noninvasive monitoring. Occurrence of infusion-related toxicities may require premature discontinuation of therapy. Therefore, an educated healthcare team and interdisciplinary clinical management guidelines are important to ensure the safe administration and complete course of ATG.

Mechanisms in pulmonary toxicology

Specific accumulation and biotransformation of drugs cause cell injury in the lung. Evoked mechanisms are oxidative injury, direct cytotoxic effects, intracellular deposition of phospholipids, and immune reaction. Individual susceptibility can be due to genetically determined metabolic idiosyncrasy or to immune-mediated hypersensitivity.

Acute respiratory distress syndrome after kidney transplantation: epidemiology, risk factors, and outcomes

OBJECTIVE

To determine the rate of the acute respiratory distress syndrome (ARDS) after kidney transplantation and to identify risk factors associated with the development of ARDS after kidney transplantation and outcomes for patients diagnosed with ARDS in this setting.

DESIGN

Retrospective analysis of the national registry for end-stage renal disease in the United States.

PATIENTS

We studied all patients who underwent kidney transplantation between July 1, 1994 and June 30, 1998 and identified patients diagnosed with ARDS. The diagnosis of ARDS was based on coding of patients records. We also compared the rate of ARDS after kidney transplantation with the rate of ARDS in the remainder of the U.S. population based on the results of the National Hospital Discharge Survey for 1997.

MEASUREMENTS AND MAIN RESULTS

During the study period, 42,190 kidney transplantations were performed in the United States and ARDS was diagnosed in 86 of these subjects (0.2%) resulting in an annualized rate of ARDS of 51.0 cases per 100,000 patients per year. The rate of ARDS after kidney transplantation was significantly higher than the reported rate of ARDS in the U.S. population (p <.050). Demographic factors, indications for transplantation, comorbid illness, antigen mismatch, cytomegalovirus status, and development of rejection did not correlate with the development of ARDS. Of the immunosuppressive agents (e.g., cyclosporine, FK-506, mycophenolate mofetil, azathioprine, OKT-3, antilymphocyte globulin), only the use of antilymphocyte globulin when used to treat rejection was linked with an increased risk for ARDS (odds ratio: 3.85; 95% confidence interval: 1.36 to 10.87). Subjects with graft failure were 2.70 (95% confidence interval: 1.33 to 5.52) times more likely to develop ARDS. The 28-day mortality in subjects with ARDS was 52.1%. The 3-yr survival after kidney transplantation was 88.9% in those without ARDS compared with 57.8% in persons with ARDS (p <.001).

CONCLUSIONS

Although ARDS is a rare event after kidney transplantation, undergoing renal transplantation increases the risk for ARDS. Among patients receiving kidney transplants, graft failure and the use of antilymphocyte globulin for rejection are associated with the development of ARDS. Patients who develop ARDS after kidney transplantation face significant mortality.