Acute renal failure after large doses of intravenous immune globulin

OBJECTIVE: To describe a case of acute renal failure after high-dose intravenous immune Globulin (MG) therapy and the measures undertaken to prevent this complication during subsequent administration. CASE SUMMARY: A 54-year-old white man with valvular cardiomyopathy was receiving large doses (2 g/kg/mo) of MG in order to attenuate his immune system in preparation for a heart transplant. After his first infusion, he had to be rehospitalized for nausea, vomiting, fever, chills, and acute renal failure (serum creatinine [Scr] peal; 8.4 mg/dL, baseline 1.0 mg/dL). His second infusion produced similar complications. Sandoglobulin 100 mL/h (172 g; 10% solution prepared with sterile water) was used on both occasions, and the large sucrose load (1.67 g sucrose/g protein) was suspected to be the causative agent. Upon switching to Polygam (170 g; 10% solution prepared with sterile water), a glucose-containing product which only has 0.4 g glucose/g protein, and infusing it at half of the Sandoglobulin rate (50 mL/h), the patient was able to tolerate the infusion without complications (Scr and blood urea nitrogen unchanged). DISCUSSION: Stabilizing agents such as sucrose, maltose, and glucose are added to MG preparations to help reduce immunoglobulin aggregation. These aggregates are associated with some of the more serious adverse effects of MG administration. When large doses of IVIG are used, the stabilizing agents can induce an osmotic nephrosis due to the large solute lend. A review of the previous literature on MG-induced renal failure is provided, as well as the differences in the various MG formulations. Also, general guidelines are offered to prevent this complication. CONCLUSIONS: Large doses of Sandoglobulin (400-2000 mg/kg) have been associated with acute renal failure due to the large sucrose load. By taking certain precautions, especially in high-risk patients, this uncommon, but serious, adverse effect can be avoided.