Immunosuppressants in renal transplant-An offender for bronchospasm!

Dear Editor,

Renal transplantation has now been more commonly performed as it improves quality of life in immediate postoperative period.[1] Effective immunosuppressive therapy enhances survival in these types of patients.[2]

Immunosuppressive therapy includes biological agents that reduce incidence of early cellular rejection. These drugs are associated with side effects, such as fever, anaphylactoid effects including rash, bronchospasm, angioedema, hypotension, and many cardiac effects. Most commonly used agents amongst these are antithymocyte globulin (ATG) and alemtuzumab. These biological agents are associated with risk of anaphylaxis and cytokine release syndrome. Bronchospasm and hypotension from this syndrome can last for several hours to days.[1]

In one of the cases posted for renal transplant not a known case of bronchial asthma, approximately 1 h after start of ATG infusion, we observed a rise in peak airway pressures from 18 to 41 cm H2O, fall in pulmonary compliance from 47 to 10 ml/cm H2O and ABG showed fall in PaO2 from 279 to 117 mmHg [Table 1]. Chest examination showed lack of breathing sounds. There was prolonged expiratory upstroke on capnogram. Although, we had given injection hydrocortisone 100 mg and pheniramine maleate 22.75 mg intravenously, before starting infusion of ATG, rate of infusion was decreased from 25 to 5 ml/h. Inhalational anesthesia with sevoflurane was continued throughout the surgery due to its bronchodilator properties.[3] These changes in respiratory parameters slowly reverted to normal within 2 h. No hemodynamic changes or skin rash were observed during this period.

Table 1

Respiratory parameters

	Peak airway pressure (cmH20)	Compliance (ml/cm H20)	PaO2 (mmHg)
Before starting ATG	18	47	279
2 h after starting ATG	41	10	117

Thus, we conclude that prior administration of antihistaminic, slower rate of administration of ATG, and use of anaesthetic agents with bronchodilator effects can be helpful to manage this type of problem during surgery. Also, we need to be much more prepared to tackle this complication in patients with reactive airways.

As per literature search, we could not find out the incidence of this complication during transplant surgery.

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