Cytokine Release Syndrome and Cardiogenic Shock Following Anti-Thymocyte Globulin Induction in a Kidney Transplant Recipient: A Case Report

Cytokine release syndrome (CRS) is a rare but serious complication of rabbit anti-thymocyte globulin, a common induction medication for solid organ transplant recipients. We present a case of grade 4 cytokine release syndrome in a renal transplant patient in whom tocilizumab successfully salvaged the graft function and stabilized the patient. A 22-year-old woman with end-stage renal disease on hemodialysis and a complex history including systemic lupus erythematosus nephritis underwent a deceased donor kidney transplant with thymoglobulin induction. Hours postoperatively, she developed hemodynamic collapse with escalating vasopressor requirements. Elevated IL-6 supported a diagnosis of CRS, and transthoracic echocardiogram suggested acute cardiogenic shock, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Treatment with tocilizumab, an IL-6 receptor-blocking monoclonal antibody, resulted in a 76% decrease in IL-6 and subsequent gradual recovery. She was decannulated, weaned off pressors, and extubated over the next week. She was discharged 24 days postoperatively with preserved allograft function and adequate urine output that remained stable after 6 months. This report describes a rare case of severe CRS and acute cardiogenic shock after thymoglobulin induction and highlights the complexities of diagnosing shock of unknown etiology. Tocilizumab shows a promising role in treating post-transplant cytokine crisis, though reports of its use in thymoglobulin-induced CRS in perioperative kidney transplant recipients remain limited. Finally, we show how a multimodal treatment approach of tocilizumab, VA-ECMO, and best care practices was able to preserve the function of the allograft transplant.