IVIG and Dialysis Clearance
IVIG is NOT significantly cleared by hemodialysis and does not require supplemental dosing after dialysis sessions. 1
Pharmacokinetic Properties
IVIG has molecular and pharmacokinetic characteristics that make it resistant to dialysis clearance:
- High molecular weight (approximately 150,000 Da for IgG) prevents passage through dialysis membranes 1
- High degree of protein binding limits availability for dialysis removal 1
- Large volume of distribution (0.5-0.8 L/kg) means the drug distributes widely into tissues rather than remaining in plasma 1
Clinical Evidence
Direct clinical experience confirms IVIG safety during hemodialysis:
- A single-center study of 279 IVIg infusions demonstrated that administration of IVIg to patients on hemodialysis is safe and effective 1
- No dose adjustments or supplemental dosing is required for patients receiving hemodialysis 1
- IVIG can be administered during or between dialysis sessions without concern for drug loss 1
Practical Implications
Key clinical considerations for IVIG in dialysis patients:
- Standard IVIG dosing (typically 2 g/kg for immunomodulation or 0.2-0.4 g/kg every 3-4 weeks for replacement therapy) should be used without modification for renal failure or dialysis 2, 3
- Timing of administration relative to dialysis sessions does not require adjustment, unlike renally-cleared medications such as aminoglycosides or ethambutol 2
- Volume overload is the primary concern in dialysis patients receiving IVIG, not drug clearance—cardiac function and fluid status should be assessed before administration 2
Important Caveats
Monitor for IVIG-related renal complications:
- While IVIG is not cleared by dialysis, it can paradoxically cause acute kidney injury through osmotic nephrosis, particularly with sucrose-containing formulations 4, 5, 6
- Risk factors for IVIG-induced AKI include age >65 years, pre-existing renal insufficiency (creatinine clearance <60 mL/min), diabetes, high doses, and hypovolemia 4
- In patients with existing renal failure requiring dialysis, hemolytic complications from IVIG may pose greater risk than volume overload, particularly in bone marrow transplant recipients 7
- Sucrose-free formulations are preferred in patients with any degree of renal impairment 5, 6