37 ivig related acute kidney injury
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37 ivig related acute kidney injury
- 1. IVIg-associated acute renal failure
- 2. Tuesday Clinical Case Conference 11/2007 Zae Kim, MD
- 3. Days after IVIG infusion u/o 600cc 800cc 3L 3L
- 7. Acute Renal Failure After Large Doses of Intravenous Immune Globulin, Janet A Haskin, David J Warner, and Douglas U Blank, The Annals of Pharmacotherapy, 1999 July/August, Volume 33
- 8. Product characteristics Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation A Single-Center Experience_Ashley A. Vo_ Clin J Am Soc Nephrol 1 844-852, 2006 Gamunex Talecris 258 mOsm/kg 0 trace
- 12. Epidemiology - Demographic and Clinical Data of Reported Cases of Renal Failure Following IVIG Therapy Intravenous immunoglobulin and the kidney—a two-edged sword_Hedi Orbach_Seminars in Arthritis and Rheumatism_Volume 34, Issue 3, December 2004, Pages 593-601
- 13. Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation A Single-Center Experience_Ashley A. Vo_ Clin J Am Soc Nephrol 1 844-852, 2006
- 15. proximal tubular cells, which are enlarged and filled with numerous small to medium sized cytoplasmic vacuoles Trichrome stain showing extensive tubular cytoplasmic isometric vacuolization. Impairment of renal function after intravenous immunoglobulin_Sandra Soares_Neph Dial Transp_21_816_2006
- 16. Electron microscopy proximal tubular cells enlarged with numerous small to medium sized cytoplasmic vacuoles consistent with an osmotic injury Impairment of renal function after intravenous immunoglobulin_Sandra Soares_Neph Dial Transp_21_816_2006
Notas do Editor
- what
- identifies the some commonly used IVIg products Gamimune-N-10% excipient (Glycine) had the least amount of sodium chloride, had no sucrose, and is isosmolar (274 mOsm/L at 10%). Carimune is a lyophilized powder that can be reconstituted in sterile water or normal saline. It contains 1.67 g sucrose/g IVIg and at 12% in saline has an osmolality of 1074 mOsm/L and when reconstituted in sterile water has an osmolality of 768 mOsm/L. Polygam 10% also is lyophilized and can be reconstituted in sterile water or normal saline. If reconstituted in NS, Polygam 10% has an osmolality of 1250 mOsm/L. In fact, at 10%, the osmolality is identical to a 2% saline infusion In 2003, Bayer introduced Gamunex, stablizied with glycine, to date has not been associated with any reports of acute renal failure. At Tisch, Gamunex is used, while at BH Carimune (Sandoglobulin) is used
- A literature search of articles published on the efficacy of IVIG in the treatment of nephritis between 1985 and 2003 Thirty-two reports entailing 78 patients with IVIG-induced nephrotoxicity their data were compared with 88 patients reported to the FDA. -Overall, no specific differences were noted between the 2 groups of patients, as their age and indications for using IVIG were similar. -Preexisting renal disease, defined as a baseline serum creatinine of 1.4 mg/dL, was noted in 45% of case reports, while the data from the FDA reports were incomplete; in 54 cases, 26% had prior renal insufficiency ( P 0.05). -Most of the patients in both groups who developed renal toxicity received sucrose-containing IVIG products. (72% in the literature and 90% in the FDA group) The time of acute renal failure onset occurred between 1 and 10 days following IVIG administration. Peak serum creatinine levels were reached in all patients between 3 and 8 days (median, 5 days). In most cases renal failure was oliguric. -A high percentage of patients required hemodialysis, 31% in published cases and 40% in the FDA report. -The duration of the renal failure ranged from 3 to 45 days and in about 85% of cases it was reversible, with return of sCr level to baseline. -Death occurred in 10 to 15% of all patients in both groups despite treatment. All deaths were in patients with severe underlying medical conditions (pneumonia, cardiac disease, and SLE) and the extent to which renal failure contributed to their deaths was undetermined. -Renal histology done in a minority of the cases (n=9) demonstrated vacuolization and swelling of the proximal tubules c/w osmotic injury. -In the other 9 published patients -7 had tubular injury and vacuolization consistent with osmotic nephrosis; -1 patient had tubulo-interstitial infiltrates, and one had cryoglobulin deposits. -In 8 of these 9 cases the stabilizing agent used in the IVIG preparation was sucrose.
- described one institution’s experience with IVIg-related complications This study is a retrospective analysis of infusion-related AE that are associated with various IVIg products Eight (8.2%) patients (P < 0.0001) in the Carimune group developed ARF, while none of the other groups developed ARF. This finding coincides with previously report that 90% of ARF occurred with sucrose-based products. One of the patients who underwent biopsy showed “vacuolization” of proximal tubule.
- identical to those described in humans and experimental animals following infusion of hypertonic sucrose or mannitol solutions, known as “osmotic nephrosis”
- renal histology extensive vacuolization of the proximal tubules, with swelling and narrowing of the tubular lumina consistent with osmotic injury No acute glomerular inflammation or immunoglobulin deposition in the glomeruli or obstruction of the urinary tubules by immunoglobulins observed
- Anderson WA, Bethea WR. Renal lesions following administra tion of hypertonic solutions of sucrose. JAMA 1940; 114: 1983–1987 Maunsbach AB, Madden SC, Latta H. Light and electron microscopic changes in proximal tubules of rats after administra tion of glucose, mannitol, sucrose or dextran. Lab Invest 1962; 11: 421–432 Schwartz SL, Johnson CB. Pinocytosis as the cause of sucrose nephrosis. Nephron 1971; 8: 246–254
- reconstituted Sandoglobulin with sterile water instead of the NaCl 0.9% provided with the product. This reduced the osmolality of the 10% solution from approximately 1550 to 640 mOsm/kg.20 However, this was still much higher than the osmolality of the plasma (300 mOsm/kg). (ARF after large IVIg, haskin)