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Hypertension an underreported side effect of IVIG infusion
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Hypertension resulting from IV immune globulin infusion may be an underreported occurrence that requires further investigation, according to a report in Clinical Pediatrics.
A case in which a 26-month-old female, diagnosed with Kawasaki disease, developed hypertension one hour after initiation of IV immune globulin infusion, led study researcher Margaret Kissel, MD, of Yale Medical Center, and colleagues to assess the frequency of this manifestation.
The mechanism was first documented in an adult with dermatomyositis who received monthly IV immune globulin infusions, according to researchers. The patient developed hypertension during his first two infusions; and when dosage was increased because of worsening disease, he developed self-resolving hypertension in eight out of nine subsequent infusions.
A multicenter, open-label, controlled study that involved patients with various primary immune deficiency disorders also observed the manifestation. Patients received IV immune globulin infusions every 3 to 4 weeks for 12 months. The study findings indicated a hypertension incidence of 7%.
Although a handful of studies have described hypertension as a side effect of IV immune globulin infusions, none have expanded on this finding.
“We suspect that the development of transient hypertension as an adverse effect of [IV immune globulin] is underreported, and thus larger retrospective or prospective studies may be warranted…We speculate that the mechanism of transient hypertension seen in the patient with [Kawasaki disease] may be renovascular hypertension, secondary to renal artery involvement of the vasculitis. Further studies with renal ultrasound Doppler may clarify the mechanism of hypertension to better understand, monitor, and treat blood pressure elevations during [IV immune globulin] infusion and prevent further complications from arising,” the researchers concluded.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Anne H. Rowley, MD
These authors describe a patient who developed transient hypertension while receiving IV gammaglobulin therapy for Kawasaki disease. Although a diagnosis of Kawasaki disease was made on the fifth day, treatment was administered on the tenth day. It is recommended that treatment for Kawasaki disease be initiated as soon as possible after diagnosis (Newburger JW. Pediatrics. 2004; 114(6):1708-1733). With improvements in echocardiography and with improved algorithms for normal coronary artery dimensions based on body surface area, it is now known that about 30% of children with Kawasaki disease have coronary artery dilation at diagnosis, between day 4 and 10 after fever onset (Dominguez SR. Pediatr Infect Dis J. 2012) (Printz BF. J Am Coll Cardiol. 2011; 57(1):86-92), indicating that vascular inflammation begins quite early in the course.
The authors suggest that hypertension from IV gammaglobulin infusion may be more common than is generally appreciated. This could be true, but seems unlikely in view of the protocols for frequent vital signs monitoring during such infusions in place at most hospitals. The authors postulate that hypertension in this patient may have been the result of renal artery vasculitis. However, if the patient’s echocardiograms remained normal, the likelihood of renal artery involvement from Kawasaki disease seems remote. Moreover, if the hypertension was due to renal artery vasculitis, it would be likely to persist, rather than rapidly resolve as it did in this patient.
This case report serves to remind physicians that they should be alert for both common and rare complications from IV gammaglobulin infusions.
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