Immune globulin therapy and kidney disease: Overview and screening, monitoring, and management recommendations

Abstract

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose This report calls attention to the potential risks of diminished kidney function when administering immune globulin (IG). The goal is to increase awareness of chronic kidney disease (CKD) and kidney function impairment in patients receiving IG and provide recommendations for screening, monitoring, and management to promote risk prevention and mitigation. Summary Human IG preparations for intravenous (IVIG) or subcutaneous (SCIG) administration are the mainstay of treatment in patients with primary immunodeficiency diseases. Increasingly, IVIG at high doses (1,000 to 2,400 mg/kg) is also used as a treatment for a variety of autoimmune and inflammatory conditions. Although some autoinflammatory disorders respond to a single course of IVIG therapy, the majority of patients require long-term, regular infusions, thereby increasing the overall risks. Often, both patients and physicians treating adults with IG are unaware of underlying CKD or kidney function impairment. This lack of awareness constitutes a major risk factor for potential worsening, particularly when using high doses of IVIG. Therefore, screening of all patients for CKD and kidney function impairment before the use of IG is essential. Identification of the cause of kidney impairment is strongly encouraged, as IG therapy may need to be modified. Conclusion As detailed here, there are potential risks to patients with impaired kidney function with administration of IG, particularly at high doses. Product selection, volume, route of administration, and rate of infusion may impact those with compromised kidney function. Therefore, screening of all patients for CKD and kidney function impairment before the use of IVIG and SCIG, as well as ongoing monitoring and management, is critical. As with all potential adverse drug reactions, the best approach is to prevent them.

The use of intravenous immunoglobulin in the treatment of Hashimoto’s encephalopathy: case based review

“…Renal impairment, another delayed side effect associated with intravenous immunoglobulin therapy, usually affects patients with preexisting renal dysfunction, diabetes, advanced age and dehydration. It can be avoided with a correct assessment of risk factors, proper pre-treatment hydration, urine output and kidney function monitoring and avoidance of sucro-stabilized immunoglobulin products which can induce renal failure by osmotic injury ( 106 ). Other delayed adverse affects are represented by pseuhohyponatremia, neutropenia, autoimmune hemolytic anemia, seizures, aseptic meningitis ( 107–111 ).…”

A Review of Intravenous Immunoglobulin in the Treatment of Neuroimmune Conditions, Acute COVID-19 Infection, and Post-Acute Sequelae of COVID-19 Syndrome

“…Additionally, patients may experience site irritation and bruising, vein collapse, drug extravasation, and infection as a result of IV administration(Doyle et al, n.d.). Potentially serious reactions have been reported in 2-6% of patients(Misbah & Chapel, 1993), such as anaphylaxis, renal and cardiovascular complications, aseptic meningitis, and Transfusion-Related Acute Lung Injury (TRALI) (Guo, Tian, Wang, & Xiao, 2018).Renal complications of IVIG and SCIG include acute tubular necrosis, proximal tubular nephropathy, acute renal failure, and osmotic nephrosis due to osmotic stress to the proximal tubules in the kidneys(Kobayashi & Rigas, 2022). As a result, patients with pre-existing renal co-morbidities are recommended not to infuse IVIG at a rate exceeding 100 ml/hr (Y. J Lee et al, 2007)…”