Merieux Anti-Thymocyte Immunogloblins (ATG)
- Induction therapy for high immunological risk recipients
- Treatment of vascular rejection or steroid resistant rejection (persistent biopsy proven rejection despite a course of methylprednisolone)
- known allergy to rabbit proteins
- acute viral illness
- Previous anaphylaxis to ATG
Dosage and administration
Thymoglobulin is usually administered through a central line but may be given peripherally if necessary. In such circumstances, 1000 units heparin should be added directly to 0.9% NaCl infusion bag to prevent superficial thrombophelebitis. The combination of thymoglobulin, heparin and hydrocortisone in 5% dextrose should be avoided as precipitation has been reported. Thymoglobulin should be administered through an in-line 0.22um filter.
(NB: Basiliximab is not given if using ATG for induction)
Dose: 1.5mg/kg in 250mls 0.9% NaCl to run over a minimum of 6 hours for 4 days (Day 0,1,2,3) for a cumulative of 6mg/kg.
No test dose required
- Day 0: First dose administered in recovery suite as soon as possible post transplantation after 500mg methyl prednisolone has been given via CVP line.
- Day 1: As for Day 0 (following second dose of 500mg methylprednisolone, with 1g paracetamol PO and 10mg chlorpheniramine IV)
- Day 2,3: Premedication of Hydrocortisone 200mg IV, paracetamol 1g PO and chlorpheniramine 10mg IV before administering thymoglobulin.
Reduce the dose by half if total WCC <3 x109/l &/or Platelets <75 x109/l.
Withhold dose if total WCC < 2 x109/l or platelet count < 50 x109/l.
NB: Tacrolimus, MMF prescribed as for standard immunosuppression. Omit oral prednisolone 20mgDay 2,3,4 and start day 5.
Treatment for acute rejection:
- The recommended dosage of Thymoglobulin for treatment of acute renal graft rejection is 1.5 mg/kg of body weight administered daily for 5 to 7 days (cumulative dose 7.5 – 10.5mg/kg). Although licensed for 7 – 14 days for AR treatment, this duration is usually not necessary.
- After the initial 5-7 days dosing, an assessment should be made, and further treatment may be given if the rejection process is ongoing.
- Reduce the dose by half if total WCC <3 x109/l and/or Platelets <75 x109/l. Dose should be withheld when total WCC < 2×109/l or platelet count < 50×109/l.
- Premedication of Hydrocortisone 200mg IV (omit oral prednisolone), paracetamol 1g PO and chlorpheniramine 10mg IV before administering thymoglobulin.
- A test dose is NOT needed for ATG treatment in most cases. However, if the patient has had a previous reaction to ATG or has a history of close exposure to rabbits, it may be considered [5 mg ATG in 100 ml NaCl 0.9% infused through a peripheral vein over 1 hour]. Preparation of test dose:
- Reconstitute 1 vial (25mg) with 5 ml water for injections, giving a solution of 5 mg ATG per ml.
- Take 1 ml (5mg) of solution and add to 100 ml NaCl 0.9%
First dose of ATG
ATG 1.5 mg/kg in 0.9% NaCl given over 6 – 8 hours ideally via a central line, but a wide bore peripheral line may be used. Round the dose to the nearest 25 mg.
- Reconstitute required number of vials with 5 ml dilutent per vial.
- Add contents of reconstituted vials to 0.9% NaCl, allowing 50 ml per vial (250 ml bag usually appropriate).
|Time after dose||Frequency of Observations|
|0 – 2 hours||15 minutes|
|2 – 4 hours||30 minutes|
|4 – 6 hours||Hourly|
- Anaphylaxis, with a drop in arterial pressure, respiratory distress, fever and urticaria may appear during or just after the infusion.
- Other hypersensitivity reactions include rigors (1%), fever (4%), arthralgia (1%), erythema (1%) and pruritic skin eruptions (0.5%).
- Symptoms are most commonly seen after the first injection and decrease during the course of treatment.
- Other side effects include thrombocytopenia (approx. 5%), neutropenia, serum sickness (3%) and lymphoma.
Daily: FBC and U&Es during course.
Risk of over-immunosuppression, hence the following schedule should be followed:
- Hold tacrolimus and anti-metabolite while ATG is being given. These can be reinstated the day after the final ATG dose (note that the anti-metabolite may need to be deferred depending on cell counts).
- For PCP prophylaxis use co-trimoxazole 480 mg daily, if patient allergic to co-trimoxale then the co-trimoxazole desensitization protocol should be used (see page 34). Continue if need to complete 3 month course.
- CMV and HSV prophylaxis using valganciclovir for 6 months should also be used (see page 35).
Mon-Fri 8.30 – 1700: contact unit pharmacist.
Out of hours: contact resident pharmacist, bleep 2268
Small stock held in pharmacy.
Both the dry powder and reconstituted solution to be stored in fridge; protect from light.