Hemolysis Associated with IVIG Therapy

Rationale: Intravenous immunoglobulin (IVIG) is used for treatment of various immune diseases. Although IVIG is known to contain antibodies to A and B antigens, these antibodies do not typically mediate clinically significant hemolysis. Our patient, with blood type A, developed symptomatic hemolysis soon after receiving multi-dose IVIG for treatment of interstitial lung disease.

Methods: Hemoglobin (Hg), LDH, total bilirubin (TB), haptoglobin, reticulocyte count (RC) and a DAT were evaluated prior to IVIG infusion and for two weeks after infusion.

Results: Prior to our patient's IVIG infusion, his Hg was 14.3g/dL. His other hemolysis labs were unremarkable. He received 5 infusions of IVIG (each 35g) over the course of 3 days. Three days after his last IVIG infusion, his labs showed a drop in Hg to 11.4g/dL, an increase in LDH to 574U/L,TB 2.9mg/dL, haptoglobin <10mg/dL, RC 3.3%, with a positive DAT for IgG. Anti-A,B was identified in the eluate.  Ten days post-IVIG infusion, he was hospitalized with worsening dyspnea. His Hg nadir was 7.9g/dL with reticulocytosis of 12.4%. He improved without blood transfusion. 

Conclusions: It is important for physicians to be aware that hemolysis may result after IVIG infusion. If a blood transfusion is required, it is generally recommended to transfuse type O RBCs, as these cells would be impervious to circulating anti-A,B from the IVIG. The role of titering lots of IVIG for anti-A,B is not currently established in clinical practice, as hemolysis is rare and appears to be largely dependent on recipient factors.