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Acute Renal Failure and Intravenous Immune Globulin: Occurs with Sucrose-Stabilized, but Not with D-Sorbitol–Stabilized, Formulation

Clinical Specialist—Transplant Therapeutics and Research, Department of Transplantation, Abbott Northwestern Hospital; Clinical Assistant Professor, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN

Kristine L Gilkerson, RN CCTC

Transplant Nurse Coordinator, Department of Transplantation, Abbott Northwestern Hospital

Thomas D Davin, MD

Medical Director, Department of Transplantation, Abbott Northwestern Hospital

Marc R Pritzker, MD

Transplant Cardiologist, Minneapolis Heart Institute Foundation/Abbott Northwestern Hospital

Reprints: Scott A Chapman PharmD, Department of Pharmacy, North Memorial Medical Center, 3300 Oakdale Ave. North, Robbinsdale, MN 55422-2900, fax 763/520-4169, chapm004{at}umn.edu

OBJECTIVE: To report 2 cases of acute renal failure (ARF) following administration of sucrose-stabilized intravenous immune globulin (IVIG), one of which did not recur following subsequent doses of D-sorbitol–stabilized formulation, and review the relevant literature.

CASE SUMMARIES: A 44-year-old white man awaiting heart transplantation developed ARF requiring hemodialysis following administration of sucrose-stabilized IVIG for high alloreactivity to population human leukocyte antigens. Following a return of renal function to baseline, subsequent doses of D-sorbitol–stabilized IVIG were administered without incident. A 90-year-old white man developed ARF after administration of sucrose-stabilized IVIG for monoclonal gammopathy. Renal function returned to baseline, and no subsequent IVIG doses were administered. An objective causality assessment revealed that sucrose-stabilized IVIG was the probable cause of the adverse drug event for both cases.

DISCUSSION: Several case reports of ARF secondary to IVIG have been published. Recent publications note that sucrose-stabilized IVIG products have a disproportionately high rate of ARF occurrence (88%) versus non–sucrose-stabilized formulations. Recent market data for IVIG products indicate that sucrose-stabilized products account for approximately 40% of the total IVIG market. When administered intravenously, sucrose is excreted unchanged in the urine. ARF has been reported in patients receiving large doses of intravenous sucrose.

CONCLUSIONS: ARF secondary to IVIG may be more likely to occur with sucrose-stabilized formulations. Before prescribing IVIG, clinicians should consider other nephrotoxic medications, preexisting renal function, age, diabetes mellitus, and rate of infusion. In patients at risk, it may be best to avoid sucrose-stabilized formulations.

Key Words: acute renal failure, intravenous immune globulin, sucrose

Published Online, November 9, 2004. www.theannals.com, DOI 10.1345/aph.1E040

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