What is Thymoglobulin?

Thymoglobulin is a T-cell–depleting immunosuppressive therapy used after kidney transplant:

  • Induction therapy (given around the time of transplant to prevent rejection)
  • Treatment of acute cellular rejection
  • Works by lowering T-lymphocytes to prevent immune attack on the transplanted kidney.

Important Safety Warnings

Critical Risk What You Need to Know
Infusion Reactions / Cytokine Release Syndrome (CRS) Most likely during the first and second doses. Symptoms: fever, chills, rigors, low blood pressure, shortness of breath, chest pain.
Anaphylaxis Risk Rare but possible. Must have emergency medications ready.
Infection Risk Drug causes profound immunosuppression—use neutropenic precautions PRN.
Hematologic Toxicity Can cause low WBC and platelets—verify labs before every dose.
Peripheral Vein Risk High risk of phlebitis if given peripherally. Special preparation required.

Pre-Infusion Checklist

Before starting each dose:

Checklist Item Requirement Action
Verify Order Correct dose, mg/kg/day, correct patient Confirm provider order and indication
Weight Check Current dosing weight required Use most recent transplant dosing weight
Lab Review – CBC WBC > 3,000/mm³ and Platelets > 75,000/mm³ Hold or adjust dose if below parameters
Lab Review – CMP Baseline renal/hepatic function, electrolytes Notify provider if abnormal trends
Premedications Given 30–60 min Before Required Acetaminophen + Diphenhydramine + Steroid (e.g. methylprednisolone)
Infection Prophylaxis Started Highly recommended Verify antiviral (e.g. valganciclovir) ± antifungal ± PJP (TMP-SMX)
Emergency Medications Available Must be accessible at bedside Epinephrine 1:1000, IV steroids, diphenhydramine, oxygen
IV Access Central line preferred If peripheral line used → must add heparin + hydrocortisone to NS
Line/Filter Required 0.22 micron inline filter connected
Infusion Pump Setup Confirm ordered rate and first-dose rate First dose ≥ 6 hours; later doses ≥ 4 hours
Compatibility Required No Y-site meds; dedicated line only
Vital Signs Baseline Required before starting Temp, pulse, BP, RR, O₂ sat
Patient Education Explain expected reactions and when to report symptoms Reinforce fever/chills common, report breathing issues immediately
Premedication Effect Ensure patient ready before start Confirm sedation risk from diphenhydramine
Documentation Required Initial assessment + checklist completion

Infusion Administration

Step Instructions
Diluent 0.9% Sodium chloride preferred
Filter Must use 0.22 micron inline filter
First dose rate Infuse over ≥6 hours
Subsequent doses Infuse over ≥4 hours
IV Access Central line preferred; peripheral IV allowed only with heparin + hydrocortisone in NS
Compatibility Do NOT mix with other drugs; Do NOT add to D5W if using heparin/hydrocortisone

Vital Sign Monitoring

Timing Frequency
Start of infusion Baseline
First hour Every 15 minutes
Rest of infusion Every 30 minutes
Post-infusion Monitor 1–2 hours after completion

Signs of Infusion Reaction—What to Watch For

Mild to Moderate Severe – Stop Infusion, Call Provider
Fever, chills, body aches Hypotension, shock
Rash, itching Chest pain, arrhythmia
Nausea, headache Severe dyspnea, oxygen desaturation
Back or infusion-site pain Bronchospasm, anaphylaxis

What to Do for Infusion Reactions

Reaction Severity Nursing Action
Mild Slow rate, give supportive meds
Moderate Temporarily stop, notify provider, treat symptoms
Severe (CRS/anaphylaxis) STOP immediately, call provider/rapid response, give emergency meds

Patient Teaching Tips

Explain to the patient:

  • Purpose: prevents or treats transplant rejection
  • Expect fever/chills—normal and usually managed with medications
  • Report shortness of breath, chest pain, throat tightness, hives immediately
  • Increased infection risk—practice hand hygiene, avoid sick contacts
  • Possible delay in vaccine schedules (no live vaccines)

Documentation Requirements

  • Premedications given
  • Line used / filter verified
  • Infusion start/stop time and rate
  • Vitals & assessments
  • Adverse reactions + interventions
  • Labs reviewed + hold parameters if applicable
  • Patient teaching and tolerance

Nursing Pearls

✅ First dose reactions are most common—monitor closely
✅ Check line patency—no Y-site compatibility
✅ Central line preferred to prevent phlebitis
✅ Continue infection prophylaxis
✅ Serum sickness may occur 5–15 days after therapy—report fever, joint pain, rash

References

  1. U.S. Food and Drug Administration. Thymoglobulin (Anti-thymocyte Globulin [Rabbit]) Package Insert. Revised 2024. Accessed October 26, 2025. https://www.fda.gov/media/74641/download
  2. Sanofi-Aventis Canada Inc. Thymoglobulin (Anti-thymocyte Globulin [Rabbit]) Product Monograph. Toronto, ON: Sanofi-Aventis Canada Inc.; Revised March 7, 2016. Accessed October 26, 2025. https://www.sanofi.com/assets/countries/canada/docs/products/prescription-products/thymoglobulin-en.pdf
  3. Noël C, Abramowicz D, Durand D, et al. Daclizumab versus antithymocyte globulin in high-immunological-risk renal transplant recipients. Nephrol Dial Transplant. 2017;32(10):1601-1609. https://academic.oup.com/ndt/article/32/10/1601/2374143
  4. Gaber AO, Knight RJ, Patel SJ, et al. Rabbit antithymocyte globulin induction versus no induction in renal transplantation: three-year follow-up of the Thymoglobulin Induction Study Group trial. PLoS One. 2016;11(1):e0146238. https://pmc.ncbi.nlm.nih.gov/articles/PMC4689936/
  5. Sanofi Genzyme. Thymoglobulin: Efficacy and Safety Data. Accessed October 26, 2025. https://www.thymoglobulin.com/efficacy-safety-data
  6. Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med. 2006;355(19):1967-1977. https://pubmed.ncbi.nlm.nih.gov/28376289/
  7. Sanofi Genzyme. Thymoglobulin: Dosing and Administration Guide. Accessed October 26, 2025. https://www.thymoglobulin.com/dosing