title: Perioperative effects of high doses of intraoperative thymoglobulin induction in liver transplantation.
abstract: OBJECTIVE
  To describe our single-centre experience in liver transplantation (LT) with the infusion of high perioperative thymoglobulin doses. The optimal dosage and timing of thymoglobulin(®) [antithymocyte globulin (ATG)] administration during LT remains controversial. Cytokine release syndrome, haemolytic anaemia, thrombocytopenia, neutropenia, fever and serum sickness are potential adverse effects associated with ATG infusion.
  
  
  METHODS
  Between December 2009 and December 2010, 16 adult non-randomized patients (ATG group), receiving a liver graft from a deceased donor, received an intraoperative infusion (4-6 h infusion) of thymoglobulin (3 mg/kg, ATG: Thymoglobuline(®)). These patients were compared (case control approach) with 16 patients who had a liver transplant without ATG treatment (control group) to evaluate the possible effects of intraoperative ATG infusion. The matching parameters were: Sex, recipient age (± 5 years), LT indication including viral status, MELD score (± 5 points), international normalized ratio and platelet count (as close as possible). The exclusion criteria for both groups included the following: Multi-organ or living donor transplant, immunosuppressive therapy before transplantation, contraindications to the administration of any thymocyte globulin, human immunodeficiency virus seropositivity, thrombocytopenia [platelet < 50000/μL] or leukopenia [white blood cells < 1000/μL]. The perioperative side effects (haemodynamic alterations, core temperature variations, colloids and crystalloids requirements, and surgical time) possibly related to ATG infusion and the thromboelastographic (TEG) evaluation of the ATG effects on coagulation, blood loss and blood product transfusion were analysed during the operation and the first three postoperative days.
  
  
  RESULTS
  Intraoperative ATG administration was associated with longer surgical procedures [560 ± 88 min vs 480 ± 83 min (control group), P = 0.013], an intraoperative core temperature more than 37 °C (50% of ATG patients vs 6.2% of control patients, P = 0.015), major intraoperative blood loss [3953 ± 3126 mL vs 1419 ± 940 mL (control group), P = 0.05], higher red blood cell [2092 ± 1856 mL ATG group vs 472 ± 632 mL (control group), P = 0.02], fresh frozen plasma [671 ± 1125 mL vs 143 ± 349 mL (control group), P = 0.015], and platelet [374 ± 537 mL vs 15.6 ± 62.5 mL (control group), P = 0.017] transfusion, and a higher requirement for catecholamines (0.08 ± 0.07 μg/kg per minutes vs 0.01 ± 0.38 μg/kg per minutes, respectively, in the ATG and control groups) for haemodynamic support. The TEG tracings changed to a straight line during ATG infusion (preanhepatic and anhepatic phases) in 81% of the patients from the ATG group compared to 6.25% from the control group (P < 0.001). Patients from the ATG group compared to controls had higher post-op core temperatures (38 °C ± 1.0 °C vs 37.3 °C ± 0.5 °C; P = 0.02), an increased need of noradrenaline (43.7% vs 6.25%, P = 0.037), received more platelet transfusions (31.5% vs 0%, P = 0.04) and required continuous renal replacement therapy (4 ATG patients vs none in the control group; P = 0.10). ATG infusion was considered the cause of a fatal anaphylactic shock and of a suspected adverse reaction that led to intravascular haemolysis and acute renal failure.
  
  
  CONCLUSIONS
  The side effects and the coagulation imbalance observed in patients receiving a high dosage of ATG suggest caution in the use of thymoglobulin during LT.
authors.affiliation: Lesley De Pietri, Bruno Begliomini, Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena-Policlinico, 41100 Modena, Italy.
authors.forename: Lesley
authors.initials: L
authors.lastname: De Pietri
authors.affiliation: Lesley De Pietri, Bruno Begliomini, Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena-Policlinico, 41100 Modena, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Serra
authors.affiliation: Lesley De Pietri, Bruno Begliomini, Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena-Policlinico, 41100 Modena, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Preziosi
authors.affiliation: Lesley De Pietri, Bruno Begliomini, Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena-Policlinico, 41100 Modena, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rompianesi
authors.affiliation: Lesley De Pietri, Bruno Begliomini, Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena-Policlinico, 41100 Modena, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Begliomini
keywords: Cytokine release; Immunosuppression induction; Liver transplant; Thromboelastography; Thymoglobulin