Acute renal failure after large doses of intravenous immune globulin

OBJECTIVE: To describe a case of acute renal failure after high-dose intrav enous immune Globulin (MG) therapy and the measures undertaken to prevent t his complication during subsequent administration. CASE SUMMARY: A 54-year-old white man with valvular cardiomyopathy was rece iving 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 fai lure (serum creatinine [Scr] peal; 8.4 mg/dL, baseline 1.0 mg/dL). His seco nd infusion produced similar complications. Sandoglobulin 100 mL/h (172 g; 10% solution prepared with sterile water) was used on both occasions, and t he large sucrose load (1.67 g sucrose/g protein) was suspected to be the ca usative 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 b lood urea nitrogen unchanged). DISCUSSION: Stabilizing agents such as sucrose, maltose, and glucose are ad ded to MG preparations to help reduce immunoglobulin aggregation. These agg regates are associated with some of the more serious adverse effects of MG administration. When large doses of IVIG are used, the stabilizing agents c an induce an osmotic nephrosis due to the large solute lend. A review of th e previous literature on MG-induced renal failure is provided, as well as t he 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 associ ated with acute renal failure due to the large sucrose load. By taking cert ain precautions, especially in high-risk patients, this uncommon, but serio us, adverse effect can be avoided.