Acute renal failure resulting from intravenous immunoglobulin therapy

Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation

Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.

Safety of intravenous immune globulin in an outpatient setting for patients with neuromuscular disease

INTRODUCTION

Although intravenous immune globulin (IVIg) is used to treat patients in the outpatient setting, there is limited documentation addressing the safety of this practice.

METHODS

Retrospective analysis of 438 patients with neuromuscular diseases receiving IVIg in an outpatient setting.

RESULTS

Adverse events (AE) overall occurred in 16.9% of patients. Headache was the most common AE, noted in 11.6% of patients. Serious AEs occurred in 0.91% of patients; aseptic meningitis was the only one noted. Multivariate analyses identified the following risk factors for AEs: first-lifetime course of IVIg, higher dose per course of IVIg, diagnosis of myasthenia gravis, women, and younger age.

DISCUSSION

Intravenous immune globulin is generally safe to administer in an outpatient setting. Women, myasthenia gravis patients, and those receiving their first course or a higher total dose of IVIg are at an increased risk of experiencing an AE.

Eczematous reaction to IVIG for the treatment of dermatomyositis

The use of high-dose intravenous immunoglobulin (IVIG) is an accepted therapy for patients with refractory dermatomyositis. Cases of eczematous reactions to IVIG have been reported in the literature, but to our knowledge, none in patients being treated for dermatomyositis. We report on the cases of two female patients with refractory dermatomyositis who developed pruritic, scaly pink plaques after receiving high-dose IVIG. This diffuse eczematous skin reaction to high-dose IVIG is a rare adverse event that most often occurs days after administration of therapy. Practitioners should be aware of this entity because the eczematous eruption may be extensive and can commonly worsen with subsequent re-exposure to IVIG.

Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies

OBJECTIVE

The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research.

METHODS

Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form.

RESULTS

The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM.

CONCLUSION

Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.

Intravenous immunoglobulin for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin (IVIg) is beneficial in other autoimmune diseases. This is an update of a review first published in 2001 and previously updated in 2003, 2005, 2007, 2010 and 2012. Other Cochrane systematic reviews have shown that plasma exchange (PE) significantly hastens recovery in GBS compared with supportive treatment alone, and that corticosteroids alone are ineffective.

OBJECTIVES

We had the following four objectives.1. To examine the efficacy of intravenous immunoglobulin (IVIg) in hastening recovery and reducing the long-term morbidity from Guillain-Barré syndrome (GBS).2. To determine the most efficacious dose of IVIg in hastening recovery and reducing the long-term morbidity from GBS.3. To compare the efficacy of IVIg and plasma exchange (PE) or immunoabsorption in hastening recovery and reducing the long-term morbidity from GBS.4. To compare the efficacy of IVIg added to PE with PE alone in hastening recovery and reducing the long-term morbidity from GBS.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (2 December 2013), CENTRAL (2013, Issue 12 in The Cochrane Library), MEDLINE (January 1966 to November 2013) and EMBASE (January 1980 to November 2013). We checked the bibliographies in reports of the randomised trials and contacted the authors and other experts in the field to identify additional published or unpublished data.

SELECTION CRITERIA

Randomised and quasi-randomised trials of IVIg compared with no treatment, placebo treatment, PE, or other immunomodulatory treatments in children and adults with GBS of all degrees of severity. We also included trials in which IVIg was added to another treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, extracted data and assessed quality. We collected data about adverse events from the included trials.

MAIN RESULTS

Twelve trials were found to be eligible for inclusion in this review. Seven trials with a variable risk of bias compared IVIg with PE in 623 severely affected participants. In five trials with 536 participants for whom the outcome was available, the mean difference (MD) of change in a seven-grade disability scale after four weeks was not significantly different between the two treatments: MD of 0.02 of a grade more improvement in the intravenous immunoglobulin than the plasma exchange group; 95% confidence interval (CI) 0.25 to -0.20. There were also no statistically significant differences in the other measures considered. Three studies including a total of 75 children suggested that IVIg significantly hastens recovery compared with supportive care. The primary outcome for this review, available for only one trial with 21 mildly affected children, showed significantly more improvement in disability grade after four weeks with IVIg than supportive treatment alone, MD 1.42, 95% CI 2.57 to 0.27.In one trial involving 249 participants comparing PE followed by IVIg with PE alone, the mean grade improvement was 0.2 (95% CI -0.14 to 0.54) more in the combined treatment group than in the PE alone group; not clinically significantly different, but not excluding the possibility of significant extra benefit. Another trial with 34 participants comparing immunoabsorption followed by IVIg with immunoabsorption alone did not reveal significant extra benefit from the combined treatment.Adverse events were not significantly more frequent with either treatment, but IVIg is significantly much more likely to be completed than PE.Small trials in children showed a trend towards more improvement with high-dose compared with low-dose IVIg, and no significant difference when the standard dose was given over two days rather than five days.

AUTHORS' CONCLUSIONS

A previous Cochrane review has shown that PE hastens recovery compared with supportive treatment alone. There are no adequate comparisons of IVIg with placebo in adults, but this review provides moderate quality evidence that, in severe disease, IVIg started within two weeks from onset hastens recovery as much as PE. Adverse events were not significantly more frequent with either treatment but IVIg is significantly much more likely to be completed than PE. Also, according to moderate quality evidence, giving IVIg after PE did not confer significant extra benefit. In children, according to low quality evidence, IVIg probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in patients whose treatment starts more than two weeks after onset. Dose-ranging studies are also needed and one is in progress.

Adverse postoperative outcomes in surgical patients with immune thrombocytopenia

Background

Patients with immune thrombocytopenia (ITP) are likely to have various medical co-morbidities, yet their global features regarding adverse postoperative outcomes and use of medical resources when undergoing major surgery are unknown. The objective of this study was to validate whether ITP is an independent risk factor for adverse postoperative outcomes, and to explore the potential clinical predictors of outcomes after major surgery among patients with ITP.

Methods

A retrospective population-based cohort study was conducted using Taiwan's National Health Insurance Research Database, controlling for preoperative co-morbidities by means of multiple logistic regression. Major postoperative complication and mortality rates, and in-hospital medical costs were analysed.

Results

The study included 11 085 surgical patients with ITP and 44 340 controls without ITP matched for sex, age, and type of surgery and anaesthesia. Surgical patients with ITP had a higher risk of postoperative death (odds ratio (OR) 1·89, 95 per cent confidence interval 1·57 to 2·27), and overall postoperative complications (OR 1·47, 1·39 to 1·56), and increased hospital stay (OR 1·90, 1·80 to 2·01), admission to the intensive care unit (OR 1·73, 1·63 to 1·83) and medical costs (OR 1·89, 1·79 to 1·99). Amount of preoperative platelet and/or red blood cell transfusion, emergency visits and admission to hospital for ITP care were identified as risk factors for adverse postoperative outcomes.

Conclusion

Patients with ITP undergoing surgery are at increased risk of adverse perioperative events, particularly if blood or blood product transfusion are required preoperatively, or the procedure is done as an emergency.

The safety profile of home infusion of intravenous immunoglobulin in patients with neuroimmunologic disorders

OBJECTIVES

To assess the overall safety of high-dose intravenous immunoglobulin (IG) products used to treat patients with neuroimmunological disorders in a supervised home-based setting.

METHODS

The incidence of adverse reactions was assessed in a retrospective chart review of 420 patients who consecutively received 4076, home-based, individual, intravenous immunoglobulin (IVIG) infusions between January 2009 and December 2009.

RESULTS

A total of 90 patients (21.4%) developed adverse reactions related to IVIG administration (2.6% per individual infusion). A total of 95.5% of adverse reactions were mild, and no serious side effects were observed. The incidence of adverse reactions was significantly lower in the subgroup of patients with neuroimmunological disorders who received premedication (18.2% compared with 29.3%, P = 0.02). There was no significant statistical difference in the incidence of side effects among the different brands of IVIG used in this study.

CONCLUSIONS

The combination of premedication and well-defined clinical, IVIG infusion policies may reduce the incidence of high-dose IVIG adverse reactions administered in a home-based setting in patients with neuroimmunological disorders.

Intravenous immunoglobulin for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin (IVIg) is beneficial in other autoimmune diseases. This is an update of a review first published in 2001 and previously updated in 2003, 2005, 2007 and 2010. Other Cochrane systematic reviews have shown that plasma exchange (PE) significantly hastens recovery in GBS compared with supportive treatment alone, and that corticosteroids alone are ineffective.

OBJECTIVES

To determine the efficacy of IVIg for GBS.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (15 August 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (January 1966 to August 2011) and EMBASE (January 1980 to August 2011). We checked the bibliographies in reports of the randomised trials and contacted the authors and other experts in the field to identify additional published or unpublished data.

SELECTION CRITERIA

Randomised and quasi-randomised trials of IVIg compared with no treatment, placebo treatment, PE, or other immunomodulatory treatments in children and adults with GBS of all degrees of severity. We also included trials in which IVIg was added to another treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, extracted data and assessed quality. We collected data about adverse events from the included trials.

MAIN RESULTS

In this review, seven trials with a variable risk of bias compared IVIg with PE in 623 severely affected participants. In five trials with 536 participants for whom the outcome was available, the mean difference (MD) of change in a seven-grade disability scale after four weeks was not significantly different between the two treatments: MD of 0.02 of a grade more improvement in the intravenous immunoglobulin than the plasma exchange group; 95% confidence interval (CI) 0.25 to -0.20. There were also no statistically significant differences in the other measures considered. Three studies including a total of 75 children suggested that IVIg significantly hastens recovery compared with supportive care.In one trial involving 249 participants comparing PE followed by IVIg with PE alone, the mean grade improvement was 0.2 (95% CI -0.14 to 0.54) more in the combined treatment group than in the PE alone group; not clinically significantly different, but not excluding the possibility of significant extra benefit. Another trial with 37 participants comparing immunoabsorption followed by IVIg with immunoabsorption alone did not reveal significant extra benefit from the combined treatment.Adverse events were not significantly more frequent with either treatment, but IVIg is significantly much more likely to be completed than PE.Small trials in children showed a trend towards more improvement with high-dose compared with low-dose IVIg, and no significant difference when the standard dose was given over two days rather than five days.

AUTHORS' CONCLUSIONS

A previous Cochrane review has shown that PE hastens recovery compared with supportive treatment alone. There are no adequate comparisons of IVIg with placebo in adults, but this review provides moderate quality evidence that, in severe disease, IVIg started within two weeks from onset hastens recovery as much as PE. Adverse events were not significantly more frequent with either treatment but IVIg is significantly much more likely to be completed than PE. Also, according to moderate quality evidence, giving IVIg after PE did not confer significant extra benefit. In children, according to low quality evidence, IVIg probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in patients whose treatment starts more than two weeks after onset. Dose-ranging studies are also needed.

Intravenous immunoglobulin for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin is beneficial in other autoimmune diseases.

OBJECTIVES

We aimed to determine the efficacy of intravenous immunoglobulin for Guillain-Barré syndrome.

SEARCH STRATEGY

We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register, MEDLINE and EMBASE in June 2009 using the terms 'Guillain-Barré syndrome' and 'acute polyradiculoneuritis' combined with 'intravenous immunoglobulin'.

SELECTION CRITERIA

We included randomised and quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, extracted data and assessed quality.

MAIN RESULTS

Another Cochrane systematic review has shown that plasma exchange significantly hastens recovery. In this review, five trials compared intravenous immunoglobulin with plasma exchange in 536 severely affected, mostly adult participants. The mean difference of change in a seven-grade disability scale after four weeks was not significantly different between the two treatments: 0.02 (95% CI 0.25 to -0.20) of a grade more improvement in the intravenous immunoglobulin than the plasma exchange group. There were also no statistically significant differences in the other measures considered. Three studies including a total of 75 children suggested that intravenous immunoglobulin significantly hastens recovery compared with supportive care.In one trial involving 249 participants comparing plasma exchange followed by intravenous immunoglobulin with plasma exchange alone, the mean grade improvement was 0.2 (95% CI -0.14 to 0.54) more in the combined treatment group than in the plasma exchange alone group, not significantly different but not excluding the possibility of significant extra benefit. Another trial with 37 participants comparing immunoabsorption followed by intravenous immunoglobulin with immunoabsorption alone did not reveal significant extra benefit from the combined treatment.Small trials in children showed a trend towards more improvement with high-dose compared with low-dose intravenous immunoglobulin and no significant difference when the standard dose was given over two days rather than five days.

AUTHORS' CONCLUSIONS

A previous Cochrane review has shown that plasma exchange hastens recovery compared with supportive treatment alone. There are no adequate comparisons of intravenous immunoglobulin with placebo in adults but this review provides moderate quality evidence that, in severe disease, intravenous immunoglobulin started within two weeks from onset hastens recovery as much as plasma exchange. Adverse events were not significantly more frequent with either treatment but intravenous immunoglobulin is significantly much more likely to be completed than plasma exchange. Also according to moderate quality evidence, giving intravenous immunoglobulin after plasma exchange did not confer significant extra benefit. In children, according to low quality evidence, intravenous immunoglobulin probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in patients whose treatment starts more than two weeks after onset. Dose-ranging studies are also needed.

Information for healthcare providers on general features of IGIV with emphasis on differences between commercially available products

OBJECTIVE

Intravenous immunoglobulin (IGIV) has provided an essential replacement therapy for primary and secondary immunodeficiencies patients and prophylaxis of infectious diseases in them. It is also used in several autoimmune and chronic inflammatory disorders. An overview of IGIV with information on several commercially available IGIV products is discussed.

DATA SOURCES

Medline databases and literature provided by the manufacturer for each product presented in the manuscript.

STUDY SELECTION

From the vast body of information on IGIV, only those studies were selected that were pertinent to general features of IGIV (as presented below) or information provided by the manufacturer that facilitated comparing one product to the other.

DATA EXTRACTION

Data was extracted on production, and purification procedures, removal of infectious agents, physical and biochemical properties and issues of safety. Data was extracted only for products available in the US.

DATA SYNTHESIS

IGIV is prepared using pooled plasma. The purification of IGIV is a complex and multi-step process. There is a reciprocal relationship between the purity of IgG in the product and the recovery rate from the total plasma. It is quite possible that some of the biological mediators of the inflammatory and immune systems may be present in trace amounts. Screening and removal of blood borne pathogens is necessary and there are several different techniques available. The specifics of the administration are often variable and no consistent pattern or protocol has been used. When limited dosages are required IGIV may be administered subcutaneously. The side effects associated with IGIV are usually mild and self-limiting.

CONCLUSION

There are differences in products produced by different manufacturers. The current data does not provide sufficient detail or information to be able to make specific recommendations for the use of a given commercial preparation in a specific disease state. The use of IGIV is associated with certain common and uncommon side effects. The identification of risk factors that might predispose a patient to developing them have been studied and reported. In choosing a IGIV preparation the user may avoid features that may predispose to certain side effects. Equally important is monitoring of patients during and after the IGIV therapy.

Sugar-free, glycine-stabilized intravenous immunoglobulin prevents skin but not renal disease in the MRL/lpr mouse model of systemic lupus

Intravenous immunoglobulin (IVIG) has a therapeutic potential in many autoimmune diseases. Based on its immune modulating and complement inhibiting effects, IVIG has been tested in systemic lupus erythematosus (SLE), but due to osmotic tubular injury caused by immunoglobulin-stabilizing sugar components, lupus nephritis had been accelerated in some patients, thus IVIG use in SLE has been abandoned. The availability of non-sugar-stabilized IVIG raised the possible re-evaluation of IVIG for SLE. We investigated high-dose, long-term non-sugar-stabilized IVIG treatment on skin and renal SLE manifestations in the MRL/lpr mouse model. Animals were treated once a week with glycine-stabilized IVIG or saline (0.2 ml/ 10 g BW) from 6 weeks until they were humanely killed at 5 months of age. IVIG diminished macroscopic cutaneous lupus compared with saline treated mice. Histology and complement-3 immunostaining also demonstrated a significant reduction of skin disease after IVIG treatment. However, renal histology and function were similar in both groups. Compared with typical osmotic tubular damage induced by 5% sucrose and 10% maltose (used for IVIG stabilization), we did not observe any osmotic tubular injury in the glycine-stabilized IVIG treated mice. Our data demonstrate a beneficial effect of IVIG on skin lupus without renal side-effects. Deeper understanding of the organ-specific pathomechanism may aid an individualized SLE therapy.

Peripheral neuropathy

Patients presenting with symptoms of peripheral neuropathy are commonplace in the practice of generalist physicians, office based or hospitalists. Although there are at least a thousand different causes for peripheral neuropathy, the majority of patients can be properly diagnosed (and managed) based on framing the diagnostic possibilities within one of six typical scenarios. The case presentations in this article illustrate common and less common but essential presentations and the approach to evaluation and treatment. For these patients the key to success lies in the history and clinical examination findings.

Osmotic nephrosis: acute kidney injury with accumulation of proximal tubular lysosomes due to administration of exogenous solutes

Osmotic nephrosis describes a morphological pattern with vacuolization and swelling of the renal proximal tubular cells. The term refers to a nonspecific histopathologic finding rather than defining a specific entity. Osmotic nephrosis can be induced by many different compounds, such as sucrose, hydroxyethyl starch, dextrans, and contrast media. It has a broad clinical spectrum that includes acute kidney injury and chronic kidney failure in rare cases. This article discusses the pathological characteristics, pathogenesis, and various clinical entities of osmotic nephrosis.

Immunomodulators: interleukins, interferons, and IV immunoglobulin

The outstanding progress in immunology and the development of new technologies have resulted in the introduction of new immunotherapies, the so-called “immunomodulators”, for autoimmune diseases, inflammatory disorders, allograft rejection, and cancer. These immunomodulators comprise recombinant cytokines and specific blocking or depleting antibodies. Many of these therapies achieve their effect by stimulating the release of cytokines. The term cytokines includes interleukins (IL-), chemokines, growth factors, interferons (IFN), colony stimulating factors (CSF), and tumor necrosis factors (TNF). These molecules are involved in inflammation, cell proliferation and apoptosis, tissue injury and repair.

These new therapeutic tools can be associated with side effects among which nephrotoxicity. The most common immunomodulators associated with nephrotoxicity are described in Table 1. The nephrotoxic side effects of immunomodulators can be roughly divided into (ischemic) tubular necrosis, thrombotic microangiopathy, serum sickness, and autoimmune disorders.

Myasthenia gravis

Myasthenia gravis (MG) is a rare, autoimmune neuromuscular junction disorder. Contemporary prevalence rates approach 1/5,000. MG presents with painless, fluctuating, fatigable weakness involving specific muscle groups. Ocular weakness with asymmetric ptosis and binocular diplopia is the most typical initial presentation, while early or isolated oropharyngeal or limb weakness is less common. The course is variable, and most patients with initial ocular weakness develop bulbar or limb weakness within three years of initial symptom onset. MG results from antibody-mediated, T cell-dependent immunologic attack on the endplate region of the postsynaptic membrane. In patients with fatigable muscle weakness, the diagnosis of MG is supported by: 1. pharmacologic testing with edrophonium chloride that elicits unequivocal improvement in strength; 2. electrophysiologic testing with repetitive nerve stimulation (RNS) studies and/or single-fiber electromyography (SFEMG) that demonstrates a primary postsynaptic neuromuscular junctional disorder; and 3. serologic demonstration of acetylcholine receptor (AChR) or muscle-specific tyrosine kinase (MuSK) antibodies. Differential diagnosis includes congenital myasthenic syndromes, Lambert Eaton syndrome, botulism, organophosphate intoxication, mitochondrial disorders involving progressive external ophthalmoplegia, acute inflammatory demyelinating polyradiculoneuropathy (AIDP), motor neuron disease, and brainstem ischemia. Treatment must be individualized, and may include symptomatic treatment with cholinesterase inhibitors and immune modulation with corticosteroids, azathioprine, cyclosporine, and mycophenolate mofetil. Rapid, temporary improvement may be achieved for myasthenic crises and exacerbations with plasma exchange (PEX) or intravenous immunoglobulin (IVIg). Owing to improved diagnostic testing, immunotherapy, and intensive care, the contemporary prognosis is favorable with less than five percent mortality and nearly normal life expectancy.

Adverse effects of treatment with intravenous immunoglobulins for neurological diseases

Therapy with intravenous immunoglobulins (IVIg) is considered to be a safe treatment for a number of immune-mediated neurological diseases. Published data about prevalence of adverse effects range from 11 to 81%. The purpose of our study was to preserve a representative view on adverse effects by analysis of a large cohort of patients treated by IVIg. A recent prospective study reported 42.7% adverse events. The majority of patients presented with minor adverse effects, mostly asymptomatic laboratory changes. Rash or mild headache occurred especially when IVIg was administered with an infusion flow higher than 10 g/h. Severe complications like deep vein thrombosis or others are rare. In addition to its efficacy, IVIg therapy appears to be a safe therapy in immune-mediated neurological diseases. Most patients show no or minor adverse effects. Patients with pre-existent disorders like heart or renal insufficiency or immobilized patients, however, may be at higher risk for complications.

Prolonged renal failure secondary to antithymocyte globulin treatment in severe aplastic anemia

OBJECTIVE

To report a case of acute renal failure in a patient with severe aplastic anemia after administration of antithymocyte globulin (ATG).

CASE SUMMARY

A 41-year-old man diagnosed with severe aplastic anemia was treated with ATG and cyclosporine. After one dose of ATG (3012 mg, 40 mg/kg), the patient developed anuric acute renal failure, with serum creatinine 3.4 mg/dL (1.2 mg/dL at baseline) and blood urea nitrogen (BUN) 29 mg/dL (13 mg/dL at baseline), which required intermittent hemodialysis. Renal failure resolved with cessation of the drug, serum creatinine and BUN returned to baseline levels, and the patient no longer required hemodialysis.

DISCUSSION

ATG is a purified and concentrated gamma globulin, primarily a monomeric immunoglobulin G from hyperimmune serum of horses. It is widely used to treat severe aplastic anemia and to manage acute transplant rejection. This patient had no other confounding factors for the cause of the renal failure. An objective causality assessment using the Naranjo probability scale suggested that ATG was the probable cause of the acute renal failure. Primary glomerular disease was not excluded, as a renal biopsy was not performed.

CONCLUSIONS

The association between renal injury and administration of ATG remains unclear; therefore, we recommend that renal function be assessed and carefully monitored prior to and after administration of ATG.

Acute anuric renal failure secondary to intravenous immunoglobulin in diabetic nephropathy

We present a case of acute renal failure in a diabetic patient who received intravenous immunoglobulin therapy. Vigam liquid immunoglobulin was used successfully to treat vancomycin induced toxic epidermal necrolysis, but 4 days later the patient became anuric. Renal function was restored after haemofiltration. Immunoglobulin therapy is used to treat immune-mediated conditions, many of which affect the diabetic population. Renal failure is a rare side effect of immunoglobulin in patients with diabetes and impaired renal function, of which many clinicians are unaware. Caution must be exercised in such patients and the risks of immunoglobulin treatment weighed against the benefits.

Safety considerations in IGIV utilization

One of the primary patient concerns about IGIV infusions is safety. Patients and physicians are both concerned about transmission of infectious agents and product tolerability. Since the documented transmission of hepatitis C virus in 1994, the manufacturers of IGIV products have added additional steps to remove and/or deactivate viruses. There are numerous different methods employed to accomplish this goal. It is desirable to utilize methods that are separate and additive to decrease the likelihood of viral or prion transmission with the infusion of IGIV products. This article describes the different methods and the impact on enveloped and non-enveloped viruses and prions. IGIV tolerability is impacted by the pharmaceutical differences in these products. Different stabilizers such as sugars, amino acids and sodium chloride affect the osmolality of the products and their potential for adverse events. Patients with co-morbid conditions including age and impaired renal status could require a change in product, concentration and rate of administration.

Risks and side effects of therapy with plasma and plasma fractions

Transfusion of plasma can lead to adverse reactions or events. Immune-mediated reactions are most common--these include allergic and anaphylactic reactions, transfusion-related acute lung injury (TRALI) and haemolysis. They can range in severity from mild to fatal. Fluid overload and citrate toxicity can occur after rapid or massive transfusion. In developed countries, microbial transmission rates are low because of donor selection and testing. Pathogen reduction processes can be applied to either single-unit components (methylene blue) or plasma pools (solvent-detergent). They have the unwanted effect of reducing some coagulation factors but reduce viral transmission risk even further. Reactions associated with plasma products or fractions also include allergic reactions, although TRALI is rare. Viral transmission risk is very low because of the use of two independent viral inactivation steps. Different products have particular specific unwanted effects: intravenous immunoglobulin has been associated with thrombotic events, renal toxicity and aseptic meningitis; coagulation factors are associated with development of inhibitors and thrombotic events. The risk of transmission of variant Creutzfeldt-Jakob disease in both plasma components and pooled plasma products is as yet unknown. If anything, the low titre of prion infectivity in the blood of an infected individual (approximately 10 infectious units/ml) will be massively diluted by the thousands of units of plasma in the pool. Subsequent manufacturing processes also remove prions from the final product.

Drug-induced nephropathy: an update

Medications cause renal disease by promoting various types of injury in the kidney. Several drugs reduce renal perfusion and cause prerenal azotemia. Vascular disease can develop following exposure to various medications through direct and indirect effects. A number of glomerular lesions have been described with therapeutic agents and illicit drugs. Acute interstitial nephritis occurs from a drug-induced allergic reaction, which promotes interstitial inflammation and tubular damage. Acute tubular necrosis is a dose-dependent process that occurs from direct drug toxicity on tubular epithelia. Other less common patterns of drug-induced tubular injury include osmotic nephropathy, crystal nephropathy and acute nephrocalcinosis. Finally, postrenal azotemia from structural or functional obstruction of the urinary tract also complicates therapy with a number of medications.

Intravenous immunoglobulin for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin is beneficial in other autoimmune diseases.

OBJECTIVES

We aimed to determine the efficacy of intravenous immunoglobulin for treating Guillain-Barré syndrome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (March 2005), MEDLINE (January 1966 to March 2005) and EMBASE (January 1980 to March 2005) using the terms 'Guillain-Barré syndrome' and 'acute polyradiculoneuritis'.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, extracted data and assessed quality.

MAIN RESULTS

Another Cochrane systematic review has shown that plasma exchange significantly hastens recovery. We found six randomised trials comparing intravenous immunoglobulin with plasma exchange. We undertook a meta-analysis of five trials involving 536, mostly adult participants who were unable to walk unaided and had been ill for less than two weeks. Our primary outcome measure was the change in a seven-grade disability scale four weeks after randomisation. The weighted mean difference of this measure was not statistically significant, being only -0.02 (95% confidence interval -0.25 to 0.20) of a disability grade more improvement in the intravenous immunoglobulin than the plasma exchange group. There were no statistically significant differences in other measures. One trial involving 249 participants compared plasma exchange followed by intravenous immunoglobulin with plasma exchange alone. Another involving 37 participants compared immunoabsorption followed by intravenous immunoglobulin with immunoabsorption alone. Neither revealed significant extra benefit from intravenous immunoglobulin. One study with 39 participants showed a trend towards more improvement with high-dose compared with low-dose intravenous immunoglobulin. Another trial with 51 children found no significant difference in outcome when the standard dose was given over two days rather than five days. Three studies including a total of 75 participants suggested that in children intravenous immunoglobulin significantly hastens recovery compared with supportive care.

AUTHORS' CONCLUSIONS

In adults, there are no adequate comparisons with placebo. Randomised trials in severe disease show that intravenous immunoglobulin started within two weeks from onset hastens recovery as much as plasma exchange, which is known to be more effective than supportive care. Treatment with intravenous immunoglobulin is significantly more likely to be completed than plasma exchange. Giving intravenous immunoglobulin after plasma exchange did not confer significant extra benefit. In children, intravenous immunoglobulin probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in treatment starting more than two weeks after onset of the condition. Dose-ranging studies are also needed.

Adverse events associated with intravenous immunoglobulin therapy

In addition to its U.S. Food and Drug Administration (FDA) approved conditions, immune globulin intravenous (IGIV) is now being used to treat a vast array of autoimmune disorders. Some of the reasons for this overall increase in the use of IGIV include its effectiveness and safety. Despite many years of safe use, side effects and adverse reactions still occur. Common and mild side effects associated with IGIV include: headache, malaise, nausea, low-grade fever, urticaria, arthralgias, and myalgia. These symptoms typically resolve within a few days after their onset. Although rare, the serious and potentially fatal side effects include: anaphylactic reactions, aseptic meningitis, acute renal failure, stroke, myocardial infarction, and other thrombotic complications. Many of these side effects have occurred in patients who have significant, underlying risk factors for the development of the event. Thus, it is vitally important that a thorough and comprehensive medical evaluation be performed on every patient who is being evaluated for potential IGIV therapy. This evaluation can, to some extent, significantly minimize the risk of these side effects. Careful, constant, and close monitoring by trained personnel during the infusion can also result in early detection of such events. Physicians should thoroughly discuss the risks and benefits of IGIV with patients who are being considered for this therapy.

Autoimmune Myasthenia Gravis: Recommendations for Treatment and Immunologic Modulation

Treatment for myasthenia gravis should be individualized to each patient based on the clinical characteristics of myasthenia including the distribution, duration, and severity of weakness and resulting functional impairment; the risks for treatment complications related to age, gender, and medical comorbidities; and the presence of thymoma. Acetylcholinesterase inhibitors provide temporary, symptomatic treatment for all forms of myasthenia gravis. Immune modulators address the underlying autoimmune process in myasthenia gravis, but are associated with potential complications and side effects. Most patients with generalized myasthenia who have significant weakness beyond the ocular muscles and who remain symptomatic, despite treatment with cholinesterase inhibitors, are candidates for immune modulation. Although corticosteroids are effective for long-term immune modulation in myasthenia gravis, several more contemporary immunomodulators including azathioprine, cyclosporine, and mycophenolate mofetil have shown efficacy in myasthenia gravis and are used increasingly as first-line treatments and as steroid-sparing agents. Plasma exchange is used to achieve rapid improvement in patients with myasthenic crisis or exacerbation, to improve strength before a surgical procedure or thymectomy, and to minimize steroid-induced exacerbation in patients with oropharyngeal or respiratory muscle weakness. Intravenous immunoglobulin represents an alternative to plasma exchange in patients requiring relatively rapid short-term improvement in the setting of poor venous access. Because of a lack of controlled trials, the role of thymectomy in nonthymomatous myasthenia gravis is unclear, although evidence suggests that thymectomy increases the probability for myasthenic remission or improvement.

Drug-induced renal failure: a focus on tubulointerstitial disease

Therapeutic agents induce acute renal failure (ARF) by promoting various types of injury to the kidney. Acute interstitial nephritis (AIN) develops from medications that incite an allergic reaction, leading to interstitial inflammation and tubular damage. Acute tubular necrosis (ATN) is a dose-dependent process that develops from direct toxicity on tubular epithelia, typically in the absence of inflammation. Additional, less common patterns of drug-induced renal injury include osmotic nephropathy, crystal nephropathy, and acute nephrocalcinosis. This review focuses on the multitude of patterns of drug-induced renal failure due to tubulointerstitial disease.

Intravenous immunoglobulin and the kidney—a two-edged sword

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.

Acute renal failure and intravenous immune globulin: occurs with sucrose-stabilized, but not with D-sorbitol-stabilized, formulation

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 (approximately 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.

Isometric Tubular Epithelial Vacuolization in Renal Allograft Biopsy Specimens of Patients Receiving Low-Dose Intravenous Immunoglobulin for a Positive Crossmatch

BACKGROUND

Perioperative treatment with plasmapheresis and intravenous immunoglobulin (IVIG), combined with a tacrolimus-based immunosuppressive regimen, has been used successfully to allow renal transplantations in cross-match-positive recipients. A common finding in biopsy specimens of these allografts is isometric vacuolization of proximal tubular epithelium. This finding presents a diagnostic dilemma because it may occur secondary to IVIG treatment or tacrolimus nephrotoxicity.

METHODS

We compared the frequency and severity of isometric tubular vacuolization in renal allograft biopsy specimens obtained during the first 10 days after transplantation in 24 patients who received one or more postoperative treatments with IVIG (100 mg/kg; as part of a desensitization protocol also involving plasmapheresis) with specimens obtained in 91 patients who did not receive IVIG. All patients received tacrolimus. Isometric vacuolization was graded on a 0 to 4 scale based on the fraction of proximal tubules involved: 0, none; 1, less than 10%; 2, 10% to 25%; 3, 26% to 50%; 4, more than 50%.

RESULTS

There was a higher frequency of isometric tubular vacuolization (71 % vs. 31%) and more widespread involvement in patients who received IVIG and tacrolimus versus tacrolimus alone, although mean tacrolimus levels were not significantly different between these groups. In control, but not IVIG, biopsy specimens, there was a significant association between vacuolization score and blood tacrolimus level on the day of biopsy.

CONCLUSIONS

Isometric tubular vacuolization is a common finding in renal transplant biopsy specimens of patients who receive low-dose IVIG and in many cases is likely to be related, at least in part, to IVIG. In these patients, this finding should not necessarily be interpreted as indicative of tacrolimus (or cyclosporine) nephrotoxicity.

Risks associated with the use of intravenous immunoglobulin

Although US immune globulin intravenous (human) (IGIV) products have been regarded as safe, it is important to recognize that many of the controlled clinical studies of IGIVs have been of modest size and have limited power to define the incidence of only the most common adverse events (AEs). A significant number of "postmarketing" serious AEs affecting renal, cardiovascular, CNS, integumentary, and hematologic organ systems have been reported. Variables potentially affecting the risk and intensity of adverse events associated with administration of IGIV include patient age, underlying condition, history of migraine, cardiovascular or renal disease, dose, concentration, rate of infusion, specific brand/formulation/excipients, and lot(s) of the particular IGIV product being administered. Each manufacturer's IGIV preparation is a unique product carrying its own specific evidence-based indications and safety profile. In view of the seriousness of potential adverse effects of IGIV products, and current lack of data surrounding their frequency, clinicians are advised to limit their prescription of these products for conditions for which efficacy is supported by adequate and well-controlled clinical trials. Prescribers should pay close attention to patient selection; consider the potential risk/benefit ratio vis-a-vis alternate therapies; and familiarize themselves with the identification, management, and proposed strategies to minimize the risks of IGIV.

Efficacy and safety of intravenous immunoglobulin for immune-mediated skin disease: current view

Intravenous immunoglobulins (IVIgs) exert a variety of immunomodulating activities and are, therefore, increasingly being used for the treatment of immune-mediated as well as autoimmune diseases. There is also accumulating evidence that high-dose IVIg (hdIVIg) is highly efficacious in the treatment of skin diseases, despite the lack of evidence from randomized, double-blind, placebo-controlled trials. A major advantage of hdIVIg in comparison with other commonly used immunomodulating therapeutic strategies is the excellent safety profile. Accordingly, IVIgs have been used successfully for the treatment of bullous autoimmune diseases such as pemphigus and bullous pemphigoid, dermatomyositis, scleroderma, cutaneous lupus erythematosus, toxic epidermal necrolysis, and erythema exudativum multiforme. In most cases, hdIVIg is effective only in combination with other immunomodulating strategies and allows for the reduction of adjuvants. Adverse effects of hdIVIg are generally mild and self-limiting. These include headache, myalgia, flush, fever, nausea or vomiting, chills, lower backache, changes in blood pressure, and tachycardia. To avoid infusion-related rigors, headaches, and other adverse events, pre-treatment with analgesics, NSAIDs, antihistamines, or low-dose intravenous corticosteroids may be beneficial. Controlled, double-blind, long-term clinical trials and a better understanding of the complex immunomodulating mechanism of IVIg are required to ultimately optimize dose, frequency, duration, and mode of IVIg administration.

Intravenous immunoglobulin for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin purified from donated blood is beneficial in other autoimmune diseases.

OBJECTIVES

We aimed to determine the efficacy of intravenous immunoglobulin for treating Guillain-Barré syndrome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group register (search updated 11 February 2003), MEDLINE and EMBASE (from January 2000 to February 2003) using Guillain-Barré syndrome and acute polyradiculoneuritis as the search terms. We also searched bibliographies of trials and made contact with their authors and other experts.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two reviewers examined the titles and abstracts of all the papers retrieved by the search, extracted the data and assessed the quality of the trials independently.

MAIN RESULTS

Two trials comparing intravenous immunoglobulin with supportive treatment were inadequate to establish its value. Another Cochrane systematic review has shown that plasma exchange hastens recovery. We found six randomised trials that compared intravenous immunoglobulin with plasma exchange. In a meta-analysis of five trials involving 536, mostly adult, participants who were unable to walk unaided and had been ill for less than two weeks. The primary outcome measure in this review was the change in a seven grade disability scale four weeks after randomisation. The weighted mean difference of this measure was not statistically significant, being only 0.04 (95% CI -0.26 to 0.19) of a disability grade more improvement in the intravenous immunoglobulin group than the plasma exchange group. There were also no statistically significant differences in time to walk unaided, mortality, and proportion of participants unable to walk without aid after a year. One trial involving 249 participants compared plasma exchange followed by intravenous immunoglobulin with plasma exchange alone, and another involving 37 participants compared immunoabsorption followed by intravenous immunoglobulin with immunoabsorption alone. Neither revealed significant extra benefit from intravenous immunoglobulin. One study of only 39 participants showed a trend towards more improvement with high-dose compared with low-dose intravenous immunoglobulin.

REVIEWER'S CONCLUSIONS

Although there are no adequate comparisons with placebo, intravenous immunoglobulin hastens recovery from Guillain-Barré syndrome as much as plasma exchange. Giving intravenous immunoglobulin after plasma exchange is not significantly better than plasma exchange alone. Randomised trials are needed to decide the effect of intravenous immunoglobulin in children, in adults with mild disease and in adults who start treatment after more than two weeks.

Drug-induced renal failure: update on new medications and unique mechanisms of nephrotoxicity

Medications cause renal failure through a variety of mechanisms. Hemodynamic renal failure may result from drugs that reduce renal prostaglandins and hence renal blood flow and glomerular filtration rate. A relatively new group of drugs with this potential is the cyclooxygenase-2 selective inhibitors. Direct renal tubular toxicity has also been described with a number of new medications with unique effects on the epithelial cells of the kidney. These include the antiviral agents cidofovir, adefovir, and tenofovir as well as the bisphosphonate pamidronate. Additionally, crystal deposition in the kidney may promote the development of renal failure. Several different drugs have been described to induce crystal nephropathy, including the antiparasitic drug sulfadiazine, the antiviral agent acyclovir, and the protease inhibitor indinavir. Finally, an unusual form of renal failure characterized by swollen, vacuolated proximal tubular cells can develop from hyperosmolar substances. Agents recently described to induce an "osmotic nephrosis" include intravenous immunoglobulin and the plasma expander hydroxyethyl starch.

Current concepts and controversy in chronic inflammatory demyelinating polyneuropathy

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired, immune-mediated demyelinating neuropathy. It is the most common treatable acquired polyneuropathy and represents a significant number of initially undiagnosed neuropathy patients. This article reviews the common clinical, laboratory, and electrodiagnostic features of CIDP. In addition, current areas of uncertainty are discussed.

Efficacy of pulsed intravenous immunoglobulin therapy in mixed connective tissue disease

We describe a 69-year-old patient with long-standing mixed connective tissue disease who suffered from severe skin eruptions that did not respond to various immunosuppressive regimens. Therapy with high-dose intravenous immunoglobulin was successful in controlling the patient's disease without major side effects. We think that this regimen-although expensive-might be an interesting therapeutic option in selected patients with mixed connective tissue disease that is refractory to other treatment modalities.

Immunoglobulin treatment versus plasma exchange in patients with chronic moderate to severe myasthenia gravis

The purpose of this study was to compare the efficacy of high-dose intravenous immunoglobulin (IVIG) treatment with plasma exchange in patients suffering from moderate to severe myasthenia gravis (MG) in a stable phase. There are no controlled studies comparing IVIG with plasma exchange in patients who despite immunosuppressive treatment have persistent incapacitating MG symptoms. This was a controlled crossover study. Twelve patients with generalized moderate to severe MG on immunosuppressive treatment for at least 12 months were included. The patients were evaluated clinically using a quantified MG clinical score (QMGS) before and at follow-up visits after each treatment. One week after the treatments, the patients who received plasma exchange treatment showed a significant improvement in QMGS compared to baseline but although some improvement was seen after IVIG this did not reach statistical significance. Four weeks after both plasma exchange and IVIG treatments, there was a significant improvement in QMGS compared to baseline. One week and 4 weeks after treatment, no significant difference between the 2 treatments was found. Both treatments have a clinically significant effect 4 weeks out in patients with chronic MG, but the improvement has a more rapid onset after plasma exchange than after IVIG.

High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin

Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.

Intravenous immunoglobulin application following immunoadsorption: benefit or risk in patients with autoimmune diseases?

OBJECTIVE

To evaluate infection rates, side-effects and autoantibody resynthesis after immunoadsorption with and without intravenous immunoglobulin substitution.

METHODS

Thirty-five patients with autoimmune diseases who were on long-term immunoadsorption therapy participated in a prospective, randomized study. Results and conclusions. Infections were rare but similar in frequency in patients receiving combined immunoadsorption and intravenous immunoglobulins (intervention group, n=17, 1.3 infections per patient-year) and in a control group (n=18, 0.9 infections per patient-year) treated by immunoadsorption alone. The reduction in IgG achieved with two immunoadsorptions within 3 days was 95.0+/-2.5%. The extent of removal of pathogenic autoantibodies was similar to the removal of IGG: Substitution of immunoglobulins was not associated with an increased circulating IgG level before the following immunoadsorption. Infusion of immunoglobulins at a dose of 0.14 g/kg (interquartile range 0.12-0.16) body weight in patients in whom circulating immunoglobulins had been depleted was associated with a high incidence of serious side-effects; these necessitated the termination of treatment in 24% of the patients. No evidence was found that immunoglobulin administration had any beneficial effect with respect to autoantibody resynthesis after immunoadsorption.

Diabetic Lumbosacral Polyradiculoneuropathies

The pathogenic basis and treatment of diabetic polyradiculoneuropathy is a source of recent controversy as there may be two or more distinct forms of diabetic polyradiculoplexopathy. We believe that the following two categories of diabetic polyradiculoneuropathy can be made on the basis of clinically differences: 1) the more common asymmetric, painful polyradiculoneuropathy; and 2) the rare symmetric, painless, polyradiculoneuropathy. The asymmetric, painful form (also known as diabetic amyotrophy) may have an autoimmune basis, but the etiology is not clear. The natural history for diabetic amyotrophy is spontaneous improvement. Nevertheless, various immunotherapies (eg, corticosteroids and intravenous immunoglobulin (IVIg) have been tried with subsequent improvement in symptoms. Treatment is reserved only for patients with severe ongoing pain, given the significant side effects of these medications in those patients with diabetes. Prednisone and IVIg may help alleviate the pain associated with diabetic amyotrophy. Relief of pain can help patients begin physical therapy earlier, however, there are no prospective, blinded, controlled studies that demonstrate that these treatments lead to an earlier and better recovery of muscle strength compared with the natural history of the disorder. The symmetric, painless form of diabetic polyradiculoneuropathy may in fact represent chronic inflammatory demyelinating polyneuropathy (CIDP) occurring in a patient with diabetes mellitus (DM). Patients with idiopathic CIDP may improve various immunomodulating therapies, including corticosteroid treatment, plasma exchange (PE), and IVIg. In this regard, patients with the symmetric, painless, proximal diabetic polyradiculoneuropathy may also respond to corticosteroids, plasma exchange, IVIg, azathioprine, or cyclophosphamide. However, as with diabetic amyotrophy, some patients improve spontaneously without treatment. In still other patients, the neuropathy appears unresponsive to immunotherapy. In such patients, this polyradiculoneuropathy might be caused by metabolic dysfunction associated with DM. Unfortunately, from a clinical, laboratory, and electrophysiologic standpoint, it is impossible to distinguish the patients with a symmetric, painless diabetic polyradiculoneuropathy who might respond to therapy. A trial of PE can be useful in identifying patients who might have a polyradiculoplexopathy that is responsive to immunotherapy. If patients respond to PE, they may continue to receive intermittent exchanges or be switched over to prednisone or IVIg.

Treatment approaches for Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy

GBS and CIDP are important treatable forms of acquired peripheral neuropathies. GBS is a heterogeneous disorder representing at least five different entities. Three are predominantly motor: AIDP, AMSAN, and AMAN. Fisher syndrome and acute panautonomic neuropathy are other variants. Treatment for all of these conditions is the same and includes either plasma exchange or intravenous immunoglobulin. There is no indication that Guillain-Barré patients respond to corticosteroids. At the present time, it is uncertain if CIDP represents one or more disorders. Evidence favors a syndrome composed of more than one entity accounting for (1) clinical variations from subject-to-subject, ranging from symmetrical to focal neurologic deficits; (2) course variations from slowly progressive to step-wise, to relapsing; and, (3) laboratory variations in nerve conduction studies, spinal fluid protein, and nerve biopsy findings. CIDP patients respond to corticosteroids in contrast to those with GBS. CIDP improves with intravenous immunoglobulin and plasma exchange, paralleling the findings in GBS. Specific regimens of treatment for both GBS and CIDP are presented in this article and considerations that might influence one treatment regimen over another are discussed.

Intravenous immunoglobulin treatment in peripheral nerve disorders--indications, mechanisms of action and side-effects

This review summarizes observations of clinical use of high dose intravenous immunoglobulin G (IVIg) in regards to administration, kinetics, known or postulated mechanisms of action, and adverse reactions. Indications and value of IVIg for the treatment of various neuropathies with presumed autoimmune aetiology are examined. New knowledge that advances the understanding of the pathogenesis of the neuropathies and of the mechanisms of action of IVIg is discussed.

Intravenous Immunoglobulin Reduces Anti-HLA Alloreactivity and Shortens Waiting Time to Cardiac Transplantation in Highly Sensitized Left Ventricular Assist Device Recipients

Background —Recipients of left ventricular assist devices (LVADs) develop prominent B-cell hyperreactivity. We investigated the influence of anti-HLA antibodies on waiting time to cardiac transplantation in LVAD recipients and compared the effects of 2 immunomodulatory regimens on anti-HLA serum reactivity.

Methods and Results —Fifty-five previously nonsensitized LVAD recipients of a TCI device implanted between 1990 and 1996 were studied. Patients with anti-HLA antibodies received monthly courses of either intravenous immunoglobulin (IVIg) or plasmapheresis, in conjunction with cyclophosphamide. The effects of these regimens on anti-HLA alloreactivity and waiting time to transplantation were then determined by Kaplan-Meier log-rank statistics, nonparametric Wilcoxon rank-sum test, and Student’s t test. Prolongation in transplant waiting time was related to serum IgG anti–HLA class I alloreactivity. Infusion of IVIg (2 g/kg) caused a mean reduction of 33% in anti–HLA class I alloreactivity within 1 week. Waiting time to transplantation was significantly reduced by IVIg therapy and subsequently approximated that in nonsensitized patients. Side effects of IVIg (2 g/kg) were minimal and related primarily to immune complex disease. Although plasmapheresis caused a similar reduction in alloreactivity to IVIg, this effect was achieved after longer treatment. Moreover, plasmapheresis was associated with an unacceptably high frequency of infectious complications. In patients resistant to low-dose (2 g/kg) IVIg therapy, high-dose (3 g/kg) IVIg was effective in reducing alloreactivity but was associated with a high incidence of reversible renal insufficiency.

Conclusions —These results indicate that IVIg is an effective and safe modality for sensitized recipients awaiting cardiac transplantation, reducing serum anti-HLA alloreactivity and shortening the duration to transplantation. The therapeutic and safety profile of IVIg would appear to be superior to plasmapheresis.

Acute renal failure after large doses of intravenous immune globulin

OBJECTIVE

To describe a case of acute renal failure after high-dose intravenous immune globulin (IVIG) therapy and the measures undertaken to prevent this complication during subsequent administration.

CASE SUMMARY

A 54-year-old white man with valvular cardiomyopathy was receiving large doses (2 g/kg/mo) of IVIG in order to attenuate his immune system in preparation for a heart transplant. After his first infusion, he had to be rehospitalized for nausea, vomiting, fever, chills, and acute renal failure (serum creatinine [Scr] peak 8.4 mg/dL, baseline 1.0 mg/dL). His second infusion produced similar complications. Sandoglobulin 100 mL/h (172 g; 10% solution prepared with sterile water) was used on both occasions, and the large sucrose load (1.67 g sucrose/g protein) was suspected to be the causative agent. Upon switching to Polygam (170 g; 10% solution prepared with sterile water), a glucose-containing product which only has 0.4 g glucose/g protein, and infusing it at half of the Sandoglobulin rate (50 mL/h), the patient was able to tolerate the infusion without complications (Scr and blood urea nitrogen unchanged).

DISCUSSION

Stabilizing agents such as sucrose, maltose, and glucose are added to IVIG preparations to help reduce immunoglobulin aggregation. These aggregates are associated with some of the more serious adverse effects of IVIG administration. When large doses of IVIG are used, the stabilizing agents can induce an osmotic nephrosis due to the large solute load. A review of the previous literature on IVIG-induced renal failure is provided, as well as the differences in the various IVIG formulations. Also, general guidelines are offered to prevent this complication.

CONCLUSIONS

Large doses of Sandoglobulin (400-2000 mg/kg) have been associated with acute renal failure due to the large sucrose load. By taking certain precautions, especially in high-risk patients, this uncommon, but serious, adverse effect can be avoided.