ATG (Anti-thymocyte Globulin)

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.

Induction therapy

(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

Side effects:

  • 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.


See observations:

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.

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