What is the risk of nephrotoxicity associated with Intravenous Immunoglobulin (IVIG) therapy?

From the Guidelines

IVIG (Intravenous Immunoglobulin) can cause nephrotoxicity, primarily acute kidney injury, in some patients, with a risk that is higher with sucrose-containing IVIG preparations, in elderly patients, those with pre-existing kidney disease, diabetes, or volume depletion, and when using higher doses or rapid infusion rates. To minimize nephrotoxicity risk, the following strategies can be employed:

• Use sucrose-free IVIG formulations when possible
• Ensure adequate hydration before and during infusion
• Administer at the lowest effective dose
• Use slower infusion rates (starting at 0.5 mg/kg/min and gradually increasing as tolerated)
• Monitor kidney function before and after treatment For high-risk patients, consider dividing the total dose over more days (e.g., 0.4 g/kg/day over 5 days instead of 1-2 days) 1. The mechanism of IVIG nephrotoxicity involves osmotic injury to tubular cells from sucrose, immune complex formation, and hyperviscosity leading to renal microcirculation impairment. Most cases of IVIG-induced kidney injury are reversible with supportive care, but early recognition and intervention are essential for optimal outcomes.

Some key considerations for minimizing nephrotoxicity risk include:

• Patient factors: elderly patients, those with pre-existing kidney disease, diabetes, or volume depletion are at higher risk
• IVIG formulation: sucrose-containing preparations are associated with higher risk
• Dose and infusion rate: higher doses and rapid infusion rates increase the risk of nephrotoxicity
• Monitoring: regular monitoring of kidney function before and after treatment is essential for early detection of nephrotoxicity.

According to the most recent and highest quality study, the use of IVIG should be carefully considered in patients with pre-existing kidney disease, and the benefits and risks of treatment should be weighed on an individual basis 1. Additionally, the study suggests that IVIG can be a useful treatment option for patients with active glomerulonephritis, but the decision to use IVIG should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of treatment.

From the Research

Risk of Nephrotoxicity with IVIG Therapy

The risk of nephrotoxicity associated with Intravenous Immunoglobulin (IVIG) therapy is a significant concern, with several studies documenting cases of acute renal failure and renal impairment.

• The incidence of renal impairment in patients receiving IVIG therapy has been reported to be around 6.7% 2.
• The use of IVIG, particularly at high doses, can increase the risk of diminished kidney function, highlighting the need for screening, monitoring, and management to prevent and mitigate this risk 3.
• Certain risk factors, such as age > 65 years, preexisting renal failure, diabetes, and the concomitant use of other nephrotoxic agents, can increase the likelihood of acute renal failure during IVIG therapy 4.

Role of Stabilizing Agents in Nephrotoxicity

The type of stabilizing agent used in IVIG preparations may also play a role in the development of nephrotoxicity.

• Sucrose-stabilized IVIG products have been associated with a higher risk of acute renal failure compared to non-sucrose-stabilized formulations 5.
• The use of glucose-containing IVIG products, such as Polygam, may be a safer alternative in patients at risk of nephrotoxicity 6.
• However, it is essential to note that acute renal failure can occur with all types of IVIG, and clinicians should be aware of this potential complication 4.

Prevention and Management of Nephrotoxicity

To prevent and manage nephrotoxicity associated with IVIG therapy, several measures can be taken.

• Screening for chronic kidney disease and kidney function impairment before the use of IVIG is essential 3.
• Patients with risk factors for acute renal failure should receive hydration using saline solutions, and the concomitant administration of other nephrotoxic drugs should be avoided 4.
• The minimal required dose of IVIG should be used, and the flow of perfusion should be slowed (1-2 ml/kg/h) to minimize the risk of nephrotoxicity 4.