Antithymocyte globulin for steroid resistant rejection in renal transplant recipients immunosuppressed with triple therapy

Steroid resistant rejection, confirmed histologically, occurred in 35 of 187 consecutive cadaveric renal transplants treated with triple therapy (cyclosporin, azathioprine and prednisolone) in the Oxford Transplant Unit. Twenty-seven of these were treated with a rabbit antithymocyte globulin (ATG) and 19 showed recovery of function. The level of serum creatinine, the renal biopsy appearance and the requirement for dialysis at the start of ATG treatment did not predict which patients would respond to the therapy. One year after transplantation there was no significant difference between the mean plasma creatinine levels of those patients with steroid resistant rejection who had been given ATG and responded (151.6 mumol/l) and those who had responded to steroids alone (165.0 mumol/l). Adverse effects of ATG treatment included a mean fall in white cell count of 62.2% and a mean fall in platelet count of 45.1%. Two of the 27 patients who received ATG died (7.4% mortality). ATG would appear to be an effective treatment of steroid resistant rejection in patients receiving triple therapy immunosuppression, and graft function may subsequently be excellent in those patients who respond to treatment.