How do IVIG and intravenous (IV) hydroxyethyl starch (HES) cause AKI?
IVIG preparations are stabilized with sucrose (vs. maltose and glucose), which can cause “osmotic nephropathy.”
Similarly, the plasma expander HES also causes “osmotic nephropathy.” In fact, large prospective sepsis trials comparing HES with other plasma expanders demonstrate that HES use was associated with excess AKI, increased renal replacement therapy, and mortality.
Sucrose and HES are both filtered by the glomerulus and then endocytosed by proximal tubular cells. Once inside the cells, they are transported to lysosomes and can not be degraded.
The cells become swollen with enlarged lysosomes, which can cause tubular obstruction. Also, as the cells are injured, they detach from the basement membrane and are released into the tubular lumens. Risk factors include kidney impairment and high doses.