THYMOGLOBULIN (Rabbit Anti-Thymocyte Globulin)

POST-HEART TRANSPLANT

Indications

  • Refractory rejection
  • Induction therapy if serum creatinine level 1.8 or an estimated GFR of <65ml/min(Renal Sparing Protocol)
  • Induction therapy if pre-transplant PRA levels > 10% or other high risk candidate (African American or re-transplant)

Plan/Management

  • Post-operative moderate to severe rejection accompanied by significant hemodynamic compromise/clinical signs or symptoms, or induction therapy for those patients deemed to be high risk.

Laboratory

Prior to first-dose of thymoglobulin therapy and as indicated during thymoglobulin therapy, each patient should receive the following labs as necessary:

  • CBC with differential & Platelet Count daily during therapy (Monitor for leukopenia & thrombocytopenia)
  • CMP, PO4, LDH, Magnesium, Uric Acid daily
  • Flow cytometry for T-cell subsets (immunodeficient/transplant) x 1. During ATG therapy, the T-cell count should fall to < 10 cells/mm3.
  • If female patient, Beta HCG blood x 1 prior to Thymoglobulin.
  • Endomyocardial biopsy, Right heart catheterization, CXR, Echocardiogram prior to ATG therapy. These should then be repeated 7-14 days after ATG therapy completed (Timing at discretion of cardiology and cardiac surgery team).

Dose/Administration

  • Thymoglobulin (rabbit) 1.5 mg/kg IV, (round to the nearest 25 mg) daily for3-14 days or doses depending on indication:

--INDUCTION: POD #0 (given in the OR), POD#1, and POD#2 (3 total doses)

--REJECTION: Give 7-14 days, based on response

  • Run via central line using a 0.2 micron inline filter
  • Saline infusion to run over 6 hours for the first dose & then IF TOLERATED to run over 4 hours for all subsequent doses.
  • Prior to administering the first three doses of thymoglobulin therapy pre-medication with Solu-Medrol, Tylenol, and Benedryl is required. See pre-medication specifics below.
  • No test dose required prior to first dose of Thymoglobulin (rabbit)

Pre-medication

For the first three doses of Thymoglobulin (Rabbit), the following medications should be given 30 minutes prior to administration:

  • Methylprednisolone per protocol (250mg POD#1, 125mg POD#2)
  • Acetaminophen 650 mg po/pr, then every 6 hours thereafter for fever as necessary
  • Diphenhydramine 50 mg IV

Order Bedside Anaphylaxis Emergency Kit – contents listed below for use in suspected anaphylactic reaction to ATG and how to administer

  • Solucortef 100 mg IV (to be given over 30 seconds)
  • Epinephrine 1:1000, 3 vials (0.5mg SQ)
  • Diphenhydramine 50 mg IV (give 25mg over 1 minute)
  • Albuterol inhaler (give 2 puffs for anaphylaxis)
  • Three 3cc syringes
  • Ambu bag, Face Mask and Oral Airway

Anti-infective Prophylaxis

The following prophylaxis should be started at time of tx or during rejection therapy

  • Nystatin swish and swallow 5 cc po QID
  • Acyclovir 400mg po every 12 hours(if CMV LOWrisk category)
  • Valcyte 900mg daily (if CMV, MODERATE or HIGH risk)
  • Bactrim DS 1 tablet twice daily on Monday for PCPpx

Admit to ICU

For the treatment of rejection, patients should be admitted to the ICU for first dose of Thymoglobulin (rabbit). This is to ensure the patient does not have a reaction to the antibody. The remaining doses may be given on step-down unit or possibly in outpatient setting, once hemodynamic stability achieved and Thymoglobulin (rabbit) therapy is well tolerated by the patient.

Reference:

Thymoglobulin [Package Insert].Cambridge (MA): Genzyme Corp; 2009.

Revised 6/03/09