541: NEAR FATAL CYTOKINE RELEASE SYNDROME AFTER THYMOGLOBULIN ADMINISTERED FOR RENAL ALLOGRAFT REJECTION

Abstract

Learning Objectives: Thymoglobulin [anti-thymocyte globulin (rabbit)] is a polyclonal antibody against human T-cells used for prevention and treatment of renal allograft rejection. Thymoglobulin provides immunosuppression mainly through complement mediated T-cell lysis. The infusion may be associated with various reactions such as cytokine release syndrome (CRS), serum sickness, and rarely anaphylaxis. Methods: We present a case of a 70 year-old male that presented with acute rejection and renal failure status post renal transplant one month prior. On hospital day 5, he received his first infusion of thymoglobulin for treatment of acute rejection. Within a couple of hours, he became profoundly hypotensive and had acute respiratory distress. He was admitted to our SICU for further management of his severe CRS and impending respiratory failure. Upon arrival, he was treated with epinephrine, methylprednisolone, and diphenhydramine. Unfortunately, he continued to decompensate both hemodynamically and from a respiratory standpoint. He was urgently intubated and maintained on supra-therapeutic infusions of norepinephrine, vasopressin, and epinephrine. Within hours, he was treated for severe ARDS with high PEEP/high FiO2 and inhaled epoprostenol was utilized as salvage therapy. Additionally, he required continuous veno-venous hemodialysis for his severe metabolic acidosis. On ICU day 5, vasopressor support was weaned off while ventilator support was weaned off the following day. The patient was discharged from the surgical intensive care unit in stable condition. Results: This case demonstrates the successful recognition and management of suspected CRS. Cytokine release syndrome develops within minutes to hours following treatment with some immunotherapeutic agents. The massive cytokine release can then trigger an inflammatory response ranging from mild to severe. Severe cases of CRS may be life threatening, and can present with sudden onset of severe hypotension, respiratory failure, ARDS, and multi-organ dysfunction. Given the potentially life threatening nature of CRS, it is important for critical care providers to recognize this reaction in patients treated with immunosuppressive agents commonly used in medical practice today.