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Prolonged Renal Failure Secondary to Antithymocyte Globulin Treatment in Severe Aplastic Anemia

Clinical Fellow, Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston, Houston, TX

Johann P Schmolck, MD

Clinical Fellow, Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston

Kevin W Finkel, MD

Associate Professor and Division Director, Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston

John R Foringer, MD

Assistant Professor and Fellowship Program Director, Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston

Reprints: Dr. Foringer, Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston, 6431 Fannin St., MSB 4.148, Houston, TX 77030, fax 713/500-6882, john.r.foringer{at}uth.tmc.edu

OBJECTIVE: To report a case of acute renal failure in a patient with severe aplastic anemia after administration of antithymocyte globulin (ATG).

CASE SUMMARY: A 41-year-old man diagnosed with severe aplastic anemia was treated with ATG and cyclosporine. After one dose of ATG (3012 mg, 40 mg/kg), the patient developed anuric acute renal failure, with serum creatinine 3.4 mg/dL (1.2 mg/dL at baseline) and blood urea nitrogen (BUN) 29 mg/dL (13 mg/dL at baseline), which required intermittent hemodialysis. Renal failure resolved with cessation of the drug, serum creatinine and BUN returned to baseline levels, and the patient no longer required hemodialysis.

DISCUSSION: ATG is a purified and concentrated gamma globulin, primarily a monomeric immunoglobulin G from hyperimmune serum of horses. It is widely used to treat severe aplastic anemia and to manage acute transplant rejection. This patient had no other confounding factors for the cause of the renal failure. An objective causality assessment using the Naranjo probability scale suggested that ATG was the probable cause of the acute renal failure. Primary glomerular disease was not excluded, as a renal biopsy was not performed.

CONCLUSIONS: The association between renal injury and administration of ATG remains unclear; therefore, we recommend that renal function be assessed and carefully monitored prior to and after administration of ATG.

Key Words: acute renal failure, antithymocyte globulin, aplastic anemia

Published Online, April 10, 2007. www.theannals.com, DOI 10.1345/aph.1K036