The presence of preinfusion renal dysfunction increases the risk of the renal failure, with the risk greater for patients with moderate or severe renal disease. In the presence of significant renal disease an alternative therapy should be considered.
Renal biopsy shows swelling and vacuolization in the cytoplasm of the proximal tubular epithelium, which is a finding associated with a hyperosmolar insult. Antigen-antibody complex deposits are not a feature.
The renal adverse effects are independent of the concentration of the immunoglobulin solution and the rate of infusion.
High solute load due to sugars used as stabilizing agents (sucrose, glucose, sorbitol, maltose) may contribute to the nephrotoxicity. The stabilizing agents may compose 2-10% of the infused volume. Using the preparation with the lowest solute load may help reduce the adverse effect.
Patients at high risk for developing acute renal failure after IVIG administration (Epstein and Zoon, 1999):
(1) any degree of pre-existing renal insufficiency
(2) diabetes mellitus
(3) age > 65 years of age
(4) volume depletion
(5) sepsis
(6) paraproteinemia
(7) concomitant administration of nephrotoxic drugs
It is important to monitor renal function before, during and after the immune globulin therapy.
