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Renal Insufficiency After Intravenous Immune Globulin Therapy: a Report of Two Cases and an Analysis of the Literature

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Renal Insufficiency After Intravenous Immune Globulin Therapy: a Report of Two Cases and an Analysis of the Literature AMERICAN RENAL TRAINING CENTERS SERIES Renal Insufficiency after Intravenous Immune Globulin Therapy: A Report of Two Cases and an Analysis of the Literature ANTONIO V. CAYCO,*t MARK A. PERAZELLA,*t and JOHN P. HAYSLETTt *Sectjon of Nephrology, tDepart,nent of Medicine, Yale University School of Medicine, New Haven, Connecticut. Abstract. Over the past decade, intravenous immune globulin in some cases recovery may be delayed and require renal therapy (IVIG) has gained widespread use for a variety of replacement therapy. In such patients, recurrence of ARF may clinical disorders. IVIG treatment is associated with a number be avoided by selection of a preparation with a different of complications, including acute renal failure (ARF). Al- stabilizing agent. Two cases of IVIG-induced ARF are de- though the cause of IVIG-associated ARF is unknown, it may scribed, and all reported cases are analyzed to assess the be rebated to the stabilizing agent used in the IVIG preparation. probable mechanism of renal injury. (J Am Soc Nephrol 8: The development and resolution of ARF is typically rapid, but 1788-1794, 1997) Therapy with intravenous immune globulin (IVIG) was intro- We present two cases of ARF associated with IVIG therapy, duced in 1952 to replace natural deficiencies of immunoglobu- analyze reported cases for potential risk factors that may pre- bins for prophylaxis during infection (1). IVIG treatment has dispose to ARF, and discuss possible mechanism(s) involved also been demonstrated to be useful in patients with chronic in the development of IVIG-induced ARF. lymphocytic leukemia (CLL), primary immunodeficiency dis- orders, and steroid-resistant idiopathic thrombocytopenic pur- Case Reports pura (I). Recently, the indications for such treatment have Case 1 broadened to include a wide number of clinical disorders, A 5 1-yr-old white man with a 10-yr history of hypertension including Kawasaki ‘ s disease, autoimmune disorders, bums, was hospitalized with acute idiopathic thrombocytopenic pur- cytomegabovirus infections in transplant patients, gbomerulo- pura (ITP) associated with ecchymoses and epistaxis. He was nephritis, and immune-mediated neuromuscular disorders such treated with prednisone, 60 mg/d for 18 d, without improve- as myasthenia gravis, Guillain-Barr#{233} syndrome, and demyeli- ment in the platelet count (12,000/ml). He subsequently un- nating neuropathies (1). Currently, seven commercial prepara- derwent therapy with IV immune globulin (Sandoglobulin; tions of immunogbobubin are approved for intravenous admin- Sandoz, East Hanover, NJ) in a dosage of 0.4 gfkg per d for a istration. total of 5 consecutive days. The only other medication admin- Despite its widespread utilization, side effects associated istered was amlodipine, 10 mg/d. He was a nonsmoker and with IVIG therapy remain relatively uncommon (1 to 15%) and only occasionally drank alcohol. include two types of complications: (1) fever, chills, headache, Physical examination performed on the day of nephrologic myalgia, hypertension, and chest pain due to complement consultation revealed a well-developed male subject (86 kg). activation by IgG aggregates, and (2) anaphylactic reactions in His BP was 135/90 mmHg and his pulse rate was 80 beats per patients with underlying IgA deficiency ( 1 ,2). Acute renal mm without othostasis. Head and neck examination was unre- failure (ARF) was not noted as a complication of IVIG treat- markable. His lungs were clear while his heart exam revealed ment in the initial drug trials but over time has been recognized an 54 heart sound; neither a murmur nor rub was observed. The as a side effect of IVIG administration (2). On the basis of abdominal examination was benign and there was no edema. published reports, the development of ARF after IVIG therapy Ecchymoses were present on the trunk, arms, and legs. The appears to occur only rarely. neurologic examination was physiologic. The hospital course is summarized in Table 1 . A rise in serum creatinine level was noted on the third day of IVIG Received October 9, 1996. Accepted December 18, 1996. treatment and reached a peak of 4.2 mg/dl on day 8. Oliguria Correspondence to Dr. Mark A. Perazella, Yale University School of Medi- occurred on the fifth day of treatment. Urinalyses performed on eine, Section of Nephrology, LMP 2071, 333 Cedar Street. New Haven, CT 06520-8029. days 1 and 5 were negative for protein and blood and were notable only for the presence of tubular epithelial cells with 1046-6673/0801 1- 1788$03.00/0 Journal of the American Society of Nephrology abundant vacuoles. An ultrasound of the kidneys revealed Copyright © 1997 by the American Society of Nephrology normal-sized kidneys with normal echogenicity and absence of Renal Insufficiency and IVIG 1789 Table 1. Summary of clinical courses was given for 3 d (days 2 through 4). A rise in serum creatinine level was noted on the third day of treatment and reached a BP Input/Output BUN/Creatinine Hospital Day (mmHg) (L/24 h) (mg/dl) peak of 2.5 mg/dl before returning to baseline 7 d after IVIG was terminated. Urine volume decreased on the third day of Case 1 treatment and oliguria occurred several days after treatment. 1 125/80 2.5/2.8 18/1.4 Urinalysis revealed 2+ proteinuria on dipstick and micro- 2i 130/88 3.1/2.7 17/1.4 scopic examination of the urine sediment revealed the presence 3a 135/90 3.5/2.1 20/1.5 of renal tubular epithebial cells with cytoplasmic vacuobes and 4a 140/89 3.4/1.5 24/1.7 a few granular casts; no other abnormalities were found. Dur- 5a 144/92 3.5/1.0 35/2.2 ing hospitalization, nephrotoxic agents-including radiocon- 6’ 150/95 2.5/0.4 44/3.1 trast material-were not administered. BP remained normal 7 160/95 1.5/0.8 55/3.9 and the patient was asymptomatic. 8 155/92 1.0/1.8 62/4.2 9 149/92 1.1/3.5 63/3.7 10 145/90 1.2/4.1 64/3.0 Discussion 11 144/88 2.0/3.8 55/2.1 IVIG-associated ARF was first reported in 1987 (3). All 12 135/85 2.5/3.6 50/1.7 cases reported since the first report are summarized in Table 2. 13 140/88 2.8/3.3 41/1.5 Including the two cases reported here, a total of 50 cases of Case 2 IVIG-induced ARF have been published. The indications for 1 145/90 2.8/2.6 32/1.5 IVIG therapy were varied, but the majority consist of ITP, neurobogic disorders, and other hematologic diseases. In gen- 2b 135/86 2.1/2.0 30/1.4 3b 130/82 2.5/2.0 35/1.5 eral, a clinical diagnosis of IVIG-associated ARF has been 4b 136/83 2.3/1.3 38/1.7 made through the exclusion of other causes of ARF and by the 5 145/84 2.1/1.0 48/2.0 temporal association of ARF with IVIG infusion. 6 136/80 2.0/0.7 61/2.3 In the reported cases of IVIG-associated ARF, 2 1 patients 7 131/78 1.5/0.3 78/2.5 (45%) had a baseline serum creatinine level either documented 8 140/81 1.2/0.9 65/2.4 as less than 1 .5 mg/dl or stated to be normal (3-1 3), whereas 9 145/85 1.5/2.2 60/2.0 25 cases (55%) had underlying renal insufficiency defined as a 10 140/88 2.0/3.6 43/1.6 baseline serum creatinine level greater than or equal to 1.5 11 138/78 2.5/3.7 35/1.5 mg/dl or stated as abnormal (4-6,9, 1 1 , 14-2 1 ). Twenty-three patients (58%) were 65 yr of age or older (4 -10,13,18-21), a Received intravenous immunogbobubin whereas 17 patients (42%) were less than 65 yr of age (3- (Sandoglobulin, 0.4 g/kg per d). b Received intravenous immunogbobulin 5,9,11,12,14,16,17,19,22). Other reports did not mention age. (Sandoglobulin, 1.0 glkg per d). Nine patients (1 8%) were treated with IVIG for renal disease, six of whom carried a diagnosis of nephrotic syndrome (mem- branous, 4; mesangiocapillary, 1 ; minimal change, I) and three hydronephrosis. Throughout the hospital course, the patient did of whom had glomerubonephritis (4,15). not receive any known nephrotoxic agent including radiocon- The clinical course of IVIG-associated ARF generally fob- trast material. Urine output exceeded 2 L per day and the serum bowed a similar pattern. Acute renal insufficiency developed creatinine level returned to baseline by 3 and 7 d, respectively. approximately 3 d (range, 1 to 10 d) after the initiation of IVIG treatment. Oliguric renal failure appeared to occur more com- Case 2 monly than nonoliguric renal failure, and the duration of renal A 61-yr-old white woman with a history of hypertension, insufficiency was approximately 13 d (range, 3 to 42 d). Of the non-insulin--dependent diabetes melbitus, chronic renal insuf- 18 cases (including our two cases) that documented urine ficiency with a baseline creatinine level of 1 .5 mg/dl, and output, 16 patients developed oliguric renal failure (3,5-7,9- hyperlipidemia was treated with IVIG (Sandogbobulin) in a 11,14,19,21). At times, renal replacement therapy was re- dose of 1 g/kg per d for three consecutive days after failing quired. In this series, 15 patients (30%) treated with IVIG steroid therapy for chronic inflammatory demyelinating poly- underwent dialytic intervention (6-9,11,17-22).
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