Acute Renal Failure, Translocational Hyponatremia and Hyperkalemia following Intravenous Immunoglobulin Therapy

Abstract

Background/Aims: Intravenous immunoglobulin (IVIG) therapy has been associated with renal adverse effects and electrolyte disturbances. Methods: We retrospectively evaluated a cohort of 66 unselected patients with idiopathic thrombocytopenic purpura, who received 140 courses of IVIG therapy. Acute renal failure (ARF), hyponatremia and hyperkalemia, as potential complications of IVIG therapy, were assessed from 100 IVIG courses with sufficient data for analysis. Results: Thirteen out of 100 (13%) IVIG courses in 10 (15%) patients were complicated with ARF. Risk factors included advanced age, pre-existing renal impairment, use of diuretics and the presence of diabetes mellitus. All patients recovered renal function 1–2 weeks after IVIG infusion. Serum sodium (sNa) fell by 5.7 and 2.7 mmol/l (p < 0.01) in patients with and without ARF, respectively. Correspondingly, serum potassium increased by 0.7 and 0.23 mmol/l (p < 0.01). There was a strong inverse correlation (r = –0.308; p < 0.01) between changes in sNa and creatinine. Changes in serum potassium could be independently predicted by changes in both sNa and creatinine (R² = 0.11; p < 0.01). These data suggested that both hyponatremia and hyperkalemia were (a) due to the translocational effect of the osmotic load of sucrose, and (b) largely depended on the extent of IVIG nephropathy. Conclusion: In our series, ARF attributable to IVIG therapy, although not rare, was usually mild and fully reversible. High-risk patients were more susceptible to IVIG-related renal complications. Translocational hyponatremia and hyperkalemia following IVIG therapy, although unimportant in patients with normal renal function, may be of clinical significance in patients with severely compromised renal function, resulting in impaired sucrose excretion.

Clinical Laboratory Evaluation of the Syndrome of Inappropriate Secretion of Antidiuretic Hormone

“…Translocational hyponatremia and hyperkalemia after intravenous immunoglobulin therapy, although not clinically relevant in patients with normal renal function, may be of clinical significance in patients with severely compromised renal function, resulting in impaired sugar additives excretion (14,15); most cases have been reported with sucrose (14).…”

American Society of Nephrology Quiz and Questionnaire 2013

“…This movement of water from the intracellular to extracellular space can also give rise to hyperkalemia by way of solvent drag or passive diffusion (20). Although not provided in this case, the difference between the measured and calculated serum osmolality would reveal a significant osmolar gap due to accumulation of sucrose in the extracellular space.…”

Case Report: Acute Renal Failure after Administering Intravenous Immunoglobulin

“…[3][4][5][6][7] To make a diagnosis, a temporal relationship must be established with the administration of IVIG. In cases reported in the literature, the creatinine usually began to increase on day 1 to day 10 after administration, with a mean of 3 days and a creatinine peak around day 5.…”

“…3 Other more serious adverse effects include acute renal failure and electrolyte disturbances, thromboembolic events, aseptic meningitis, neutropenia and autoimmune hemolytic anema. 5,7 In a 2004 review of the literature, Orbach et al 4 compared the details of 78 patients from case reports in the literature, and compared these data with 88 patients reported to the FDA (Table 3). Similar results were found between groups.…”

“…12 The development of ARF in our patient after extending her usual 1-day infusion to 5 days seems more than coincidental, although establishing the dosage as a defi nitive risk has been inconclusive. 7,12 Risk factors for renal adverse effects are summarized in Table 4. They include age Ͼ 65 years, preexisting renal insuffi ciency, and diabetes mellitus.…”