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Denny JT, Burr AT, Balzer F, et al. Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Exp Ther Med. 2015;9(5):1915-1920doi: 10.3892/etm.2015.2349.
Denny, J. T., Burr, A. T., Balzer, F., Tse, J. T., Denny, J. E., & Chyu, D. (2015). Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Experimental and therapeutic medicine, 9(5), 1915-1920. https://doi.org/10.3892/etm.2015.2349
Denny, John T, et al. "Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review." Experimental and therapeutic medicine vol. 9,5 (2015): 1915-1920. doi: https://doi.org/10.3892/etm.2015.2349
Denny JT, Burr AT, Balzer F, Tse JT, Denny JE, Chyu D. Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Exp Ther Med. 2015 May;9(5):1915-1920. doi: 10.3892/etm.2015.2349. Epub 2015 Mar 12. PMID: 26136914; PMCID: PMC4471690.
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Exp Ther Med. 2015 May;9(5):1915-1920. doi: 10.3892/etm.2015.2349. Epub 2015 Mar 12.

Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review.

Experimental and therapeutic medicine

John T Denny, Andrew T Burr, Fred Balzer, James T Tse, Julia E Denny, Darrick Chyu

Affiliations

  1. Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA.
  2. Virtua Memorial Hospital, Department of Anesthesia, Mount Holly, NJ 08060, USA.
  3. Department of Anesthesia, New York University Medical Center, New York, NY 10016, USA.

PMID: 26136914 PMCID: PMC4471690 DOI: 10.3892/etm.2015.2349

Abstract

Rabbit anti-thymocyte globulin (rATG) is an infusion of polyclonal rabbit-derived antibodies against human thymocyte markers, which can be used to prevent and treat acute rejection following organ transplantation. However, the product monograph issued by the manufacturer (Sanofi Canada) reports that serious immune-mediated reactions have been observed following the use of rATG, consisting of anaphylaxis or severe cytokine release syndrome (CRS), which is a form of vasoplegic syndrome (VS), in which distributive shock occurs refractory to norepinephrine (NE) and vasopressin (VP). Severe infusion-associated reactions are consistent with CRS and can cause serious cardiac or respiratory problems, or in certain cases, mortality. CRS is a form of systemic inflammatory response syndrome (SIRS). In SIRS, the substantial activation of endothelial inducible nitric oxide synthase (iNOS) and smooth muscle guanylate cyclase (GC) is observed, which can produce severe hypotension that is unresponsive to conventional vasopressors. Methylene blue (MB) is a direct inhibitor of iNOS and GC and has been used as an effective treatment for VS following cardiothoracic surgery. In the present study, the successful use of MB as a rescue therapy for CRS in a patient receiving rATG following a renal transplant was reported. Following an uneventful cadaveric kidney transplant involving the intravenous (IV) administration of rATG for the induction of immunological tolerance, the patient became markedly hypotensive and tachycardic. The patient required high doses of VP and NE infusions. Following the protocol described for treating refractory VS in post-cardiac surgery patients, the decision was made to initiate the patient on an IV MB infusion. This treatment protocol was shown to improve the hemodynamic status of the patient, which enabled the withdrawal of vasopressors and suggests an important role for methylene blue in the management of refractory VS.

Keywords: cytokine release syndrome; cytokines; distributive shock; rabbit anti-thymocyte globulin; renal transplant complications; shock; thymoglobulin; vasoplegia; vasoplegic shock; vasoplegic syndrome

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