Can Intravenous Immunoglobulin (IV IG) cause impaired renal function?

From the Guidelines

Intravenous Immunoglobulin (IVIG) can cause impaired renal function, which is one of its recognized serious adverse effects. This complication is noted in the 2024 guideline for the treatment of interstitial lung disease, which lists renal insufficiency as a notable toxicity of IVIG 1. The risk of renal impairment with IVIG is also acknowledged in earlier guidelines, such as the 2015 practice parameter for the diagnosis and management of primary immunodeficiency, which recommends monitoring levels of creatinine and blood urea nitrogen in patients receiving IVIG due to the potential for exacerbating renal disease 1.

Key factors that increase the risk of IVIG-associated renal impairment include:

• Higher doses (>2g/kg)
• Rapid infusion rates
• Pre-existing kidney disease
• Diabetes
• Advanced age
• Volume depletion
• Concurrent use of nephrotoxic medications

To minimize the risk of renal impairment, healthcare providers should:

• Use lower-risk IVIG formulations (those without sucrose)
• Ensure adequate hydration before and during infusion
• Administer IVIG at the slowest feasible rate
• Monitor renal function before and after treatment, as recommended in the guidelines 1.

Most cases of IVIG-induced renal impairment are reversible with discontinuation of the medication, though some patients may require temporary dialysis. Given the potential for serious renal adverse effects, monitoring renal function is crucial in patients receiving IVIG, particularly those with risk factors for renal impairment.

From the FDA Drug Label

ADVERSE REACTIONS ... a few isolated occurrences of ... nephrotic syndrome, The FDA drug label mentions nephrotic syndrome, which is a condition that can cause impaired renal function, as an adverse reaction to IV IG.

• Renal impairment is a possible adverse effect of IV IG, as evidenced by the occurrence of nephrotic syndrome. This suggests that IV IG can cause renal impairment in some cases, although it is described as a rare occurrence 2.

From the Research

IV IG and Renal Impairment

• IV IG can cause impaired renal function, as reported in several studies 3, 4, 5, 6, 7.
• The exact incidence of renal impairment due to IV IG is unknown, but it is estimated to be around 1-6.7% 4, 5.
• Risk factors for IV IG-induced renal impairment include:
  • Age > 65 years 5, 6
  • Preexisting renal failure (creatinine clearance < 60 ml/min) 5, 6, 7
  • Diabetes 5, 6
  • High doses of IV IG 3, 5
  • Hypovolemia 5
  • Concomitant use of other nephrotoxic agents 5
• The mechanism of IV IG-induced renal impairment is thought to be related to osmotic nephrosis, particularly in the proximal tubule 5, 7.
• Renal function usually recovers within 1-2 weeks after IV IG infusion, but some patients may develop irreversible renal failure 4, 7.
• Screening for chronic kidney disease (CKD) and kidney function impairment before IV IG therapy is essential, and ongoing monitoring and management are critical to prevent and mitigate potential risks 3.