Nephrotoxicity of intravenous immunoglobulin in the setting of liver transplantation or HBV-related cirrhosis: an undervalued topic.

It is well recognized that acute and/or chronic renal failure is a frequent complication after orthotopic liver transplantation (OLT). The multifactorial nature of the etiology of early as well as late renal failure in patients affected by HBV-related cirrhosis is not adequately appreciated by the transplant community, since renal dysfunction has mainly attributed to calcineurin inhibitor toxicity, alone or in combination with potentially nephrotoxic drugs. In the meanwhile the potential nephrotoxicity of some intravenous immunoglobulin (IVIg) preparations that more than other could affect the renal function was completely unattended. The use of polyvalent immunoglobulins has been associated in the past with several unresolved issues, including potential nephrotoxicity. Pathologic examination of the kidneys generally reveals changes typical of the osmotic nephrosis. The hypothesis of osmotic nephrosis is further supported by the fact that in most cases, acute renal failure has been associated, in the past, with the sucrose-containing IVIg products. In patients who underwent OLT for hepatitis B virus(HBV)-related liver disease the use of anti HBV immunoglobulins (HBIg) to avoid HBV-recurrence is highly effective and has really changed the outcome of this transplantation procedure. Nevertheless, the inappropriate use of HBIg could increase the risk of renal dysfunction, particularly in combination with nephrotoxic drugs.