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Semin Arthritis Rheum. 2004 Dec;34(3):593-601.
Intravenous immunoglobulin and the kidney--a two-edged
sword.
Orbach H, Tishler M, Shoenfeld Y.
Department of Medicine B'Wolfram Medical Center, Holon,
Israel.
OBJECTIVES: To review the literature on the
use and efficacy of intravenous immunoglobulin (IVIG) in
glomerulonephritis and to evaluate the nephrotoxic effect of
IVIG. METHODS: A structured literature search of articles
published on the efficacy of IVIG in the treatment of
nephritis between 1985 and 2003 was conducted. All articles
dealing with lupus nephritis, IgA nephropathy, Henoch
Schonlein purpura, antineutrophil cytoplasmic antibodies (ANCA)
associated vasculitis, primary membranous glomerulonephritis,
and primary chronic nephritis were reviewed. The same
literature search was conducted for the nephrotoxic effects
of IVIG. Two groups of patients were defined: (a) a group of
patients with IVIG nephrotoxic effect published as case
reports, and (b) a group of patients whose data were
collected by the Food and Drug Administration (FDA). All
existing data of both groups were pooled and compared.
RESULTS: One hundred six patients with lupus nephritis were
treated with IVIG. In most reports proteinuria, nephrotic
syndrome, and values of creatinine clearance were improved.
In 3 cases improvement in World Health Organization (WHO)
class was noted, and in 2 cases a reduction of immune
deposits was demonstrated. In the other forms of autoimmune
nephropathy, although the number of reported cases was
small, improvement was noted in most patients. Thirty-two
reports entailing 78 patients with IVIG-induced
nephrotoxicity were found and their data were compared with
those of 88 patients reported to the FDA. No specific
differences were noted between the 2 groups of patients, as
their age and indications for using IVIG were similar. Most
of the patients who developed renal toxicity (72% in the
literature and 90% in the FDA group) received sucrose
-containing IVIG products. A high percentage of patients
(31% in the literature and 40% in the FDA group) required
hemodialysis. Mortality occurred in 10 and 15%,
respectively. Renal histology done in a minority of the
cases demonstrated vacuolization and swelling of the
proximal tubules consistent with osmotic injury.
CONCLUSIONS: On one hand, there are encouraging reports on
the efficacy of IVIG in different types of
glomerulonephritis (mainly lupus nephritis) resistant to
conventional therapy, but the exact success rate and
clinical indications remain undetermined. On the other hand,
IVIG and the kidney is a two-edged sword, since
nephrotoxicity can be a serious rare complication of IVIG
therapy. Products containing sucrose as a stabilizer are
mainly associated with such injury through the mechanism of
osmotic nephrosis. Preexisting renal disease, volume
depletion, and old age are risk factors for such toxicity. -
Intravenous immunoglobulin (IVIg) therapy in MPO-ANCA
related polyangiitis with rapidly progressive
glomerulonephritis in Japan.
Muso E,
Ito-Ihara T A, Suzuki K.
Division of Nephrology,
Kitano Hospital, The Tazuke Kofukai Medical Research
Institute, Osaka, Japan.
For 30 myeloperoxidase (MPO)
antineutrophil cytoplasmic antibody (ANCA) related
rapidly progressive glomerulonephritis patients (male
17, female 13, average age of 68 +/- 11.8 years old),
intravenous immunoglobulin (IVIg) (400 mg/kg/day) was
administered for 5 consecutive days before or along with
conventional immunosuppressive therapy in Japan. Twenty
patients were treated with IVIg before the start or
newly increase of conventional therapy and evaluated the
independent effect of this therapy. In these patients,
just after IVIg, significant decrease of CRP from 8.61
+/- 5.77 to 5.47 +/- 4.50 mg/dl (P < 0.001) was noted
with improvement of elevated serum creatinine in 12 out
of 19 patients (63%). In the analysis of the overall
outcome of 30 patients, at 3 months after IVIg and
following conventional therapy, no patients showed renal
death except 4 for whom hemodialysis had been started
before IVIg. At 6 months, renal survival rate were 92%
(newly renal death 2 out of 26) and 2 patients died due
to cerebral bleeding (survival rate was 93%). No fatal
infection was noted. IVIg might be the potent inducible
therapy which can be promoted before the beginning of
conventional immunosuppressant treatment for relatively
aged and lower immunopotent MPO-ANCA patients in Japan.
PMID: 15507757 [PubMed - indexed for MEDLINE] -
Nippon Jinzo Gakkai Shi. 2004 Feb;46(2):79-83
[Successful treatment of severe ANCA-associated RPGN
with high-dose IVIg therapy]
Gomada M,
Akamatsu A.
Division of Nephrology, Ehime
Prefectural Central Hospital, Ehime, Japan.
We
report a case of anti-neutrophil cytoplasmic
antibody(ANCA)-associated rapid progressive
glomerulonephritis (RPGN) that was treated with
intravenous immunoglobulin (IVIg) therapy. A 37-year-old
woman was admitted to our hospital because of a
low-grade fever, general malaise, and a poor appetite.
At the time of admission, her renal function had
severely deteriorated (serum creatinine level 9.5 mg/dl;
mean Ccr 3.3 ml/min) and she had severe anemia (Hb 6.6
g/dl). An immunological examination revealed the
presence of ANCA-associated RPGN. A biopsy confirmed a
diagnosis of pauci-immune-type necrotizing crescentic
glomerulonephritis. After initial treatment with steroid
pulse therapy (methylprednisolone, 1,000 mg/day x 3
days), her general condition deteriorated and two
sessions of hemodialysis were required. On the 10th
hospital day, a high dose of immunoglobulin was
administered intravenously (IVIg 400 mg/kg/day x 5
days). This therapy immediately improved her general
condition and lowered her serum titer of MPO-ANCA
anti-neutrophil cytoplasmic antibody and her serum
creatinine level. After two IVIg treatments, her
MPO-ANCA titer returned to a normal level and her serum
creatinine level improved from 9.5 mg/dl to 3.3 mg/dl. A
second biopsy confirmed clinical improvement. These
findings suggest that IVIg therapy is effective for
cases of ANCA-associated glomerulonephritis that are
difficult to treat using conventional immunosuppressive
therapy.
PMID: 15058108 [PubMed -
indexed for MEDLINE]
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