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Grigoriadou S, Clubbe R, Garcez T, Huissoon A, Grosse-Kreul D, Jolles S, Henderson K, Edmonds J, Lowe D, Bethune C. British Society for Immunology and United Kingdom Primary Immunodeficiency Network (UKPIN) consensus guideline for the management of immunoglobulin replacement therapy. Clin Exp Immunol 2022; 210:1-13. [PMID: 35924867 PMCID: PMC9585546 DOI: 10.1093/cei/uxac070] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/08/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023] Open
Abstract
Currently, there is no guideline to support the use of immunoglobulin replacement therapy (IgRT) in primary and secondary immunodeficiency disorders in UK. The UK Primary Immunodeficiency Network (UK-PIN) and the British Society of Immunology (BSI) joined forces to address this need. Given the paucity of evidence, a modified Delphi approach was used covering statements for the initiation, monitoring, discontinuation of IgRT as well as home therapy programme. A group of six consultant immunologists and three nurse specialists created the statements, reviewed responses and feedback and agreed on final recommendations. This guideline includes 22 statements for initiation, 22 statements for monitoring, 11 statement for home therapy, and 19 statements for discontinuation of IgRT. Further areas of research are proposed to improve future delivery of care.
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Affiliation(s)
- S Grigoriadou
- Department of Immunology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - R Clubbe
- National Guideline Centre, Royal College of Physicians, London, UK
| | - T Garcez
- Immunology Department, Manchester University NHS Trust, Manchester, UK
| | - A Huissoon
- West Midlands Immunodeficiency Centre, Birmingham Heartlands Hospital, Birmingham, UK
| | - D Grosse-Kreul
- Department of Immunological Medicine, King’s College Hospital, London, UK
| | - S Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - K Henderson
- Immunology Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Edmonds
- Immunology Department, Manchester University NHS Trust, Manchester, UK
| | - D Lowe
- UCL Institute of Immunity and Transplantation, Royal Free Hospital, London, UK
| | - C Bethune
- Peninsula Immunology and Allergy Service, University Hospitals Plymouth, Plymouth, UK
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2
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Immune Gamma Globulin Therapeutic Indications in Immune Deficiency and Autoimmunity. Curr Allergy Asthma Rep 2017; 16:55. [PMID: 27401913 DOI: 10.1007/s11882-016-0632-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune gamma globulin (IgG) has a long history in the treatment of both primary immune deficiency and autoimmune disorders. Disease indications continue to expand and new-generation products increase the versatility of delivery. This review encompasses a historical perspective as well as current and future implications of human immune globulin for the treatment of immune-mediated illness.
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 371] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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Gathmann B, Mahlaoui N, Gérard L, Oksenhendler E, Warnatz K, Schulze I, Kindle G, Kuijpers TW, van Beem RT, Guzman D, Workman S, Soler-Palacín P, De Gracia J, Witte T, Schmidt RE, Litzman J, Hlavackova E, Thon V, Borte M, Borte S, Kumararatne D, Feighery C, Longhurst H, Helbert M, Szaflarska A, Sediva A, Belohradsky BH, Jones A, Baumann U, Meyts I, Kutukculer N, Wågström P, Galal NM, Roesler J, Farmaki E, Zinovieva N, Ciznar P, Papadopoulou-Alataki E, Bienemann K, Velbri S, Panahloo Z, Grimbacher B. Clinical picture and treatment of 2212 patients with common variable immunodeficiency. J Allergy Clin Immunol 2014; 134:116-26. [PMID: 24582312 DOI: 10.1016/j.jaci.2013.12.1077] [Citation(s) in RCA: 390] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 12/03/2013] [Accepted: 12/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is an antibody deficiency with an equal sex distribution and a high variability in clinical presentation. The main features include respiratory tract infections and their associated complications, enteropathy, autoimmunity, and lymphoproliferative disorders. OBJECTIVE This study analyzes the clinical presentation, association between clinical features, and differences and effects of immunoglobulin treatment in Europe. METHODS Data on 2212 patients with CVID from 28 medical centers contributing to the European Society for Immunodeficiencies Database were analyzed retrospectively. RESULTS Early disease onset (<10 years) was very frequent in our cohort (33.7%), especially in male subjects (39.8%). Male subjects with early-onset CVID were more prone to pneumonia and less prone to other complications suggesting a distinct disease entity. The diagnostic delay of CVID ranges between 4 and 5 years in many countries and is particularly high in subjects with early-onset CVID. Enteropathy, autoimmunity, granulomas, and splenomegaly formed a set of interrelated features, whereas bronchiectasis was not associated with any other clinical feature. Patient survival in this cohort was associated with age at onset and age at diagnosis only. There were different treatment strategies in Europe, with considerable differences in immunoglobulin dosing, ranging from 130 up to 750 mg/kg/mo. Patients with very low trough levels of less than 4 g/L had poor clinical outcomes, whereas higher trough levels were associated with a reduced frequency of serious bacterial infections. CONCLUSION Patients with CVID are being managed differently throughout Europe, affecting various outcome measures. Clinically, CVID is a truly variable antibody deficiency syndrome.
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Affiliation(s)
- Benjamin Gathmann
- Center for Chronic Immunodeficiency (CCI), University Medical Centre Freiburg and University of Freiburg, Freiburg, Germany
| | - Nizar Mahlaoui
- Assistance Publique-Hôpitaux de Paris, Service d'Immuno-Hématologie Pédiatrique, Hôpital Universitaire Necker-Enfants Malades, Paris, France, Assistance Publique-Hôpitaux de Paris, CEREDIH, Centre de Référence des Déficits Immunitaires Héréditaires, Hôpital Universitaire Necker-Enfants Malades, Paris, France, and Université Paris Descartes - Sorbonne Paris Cité, Institut Imagine, Paris, France
| | | | - Laurence Gérard
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP and Univ Paris Diderot, Sorbonne Paris Cité, EA3963, Paris, France, Centre de Référence Déficits Immunitaires Héréditaires (CEREDIH), Paris, France, and the DEFI study group
| | - Eric Oksenhendler
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP and Univ Paris Diderot, Sorbonne Paris Cité, EA3963, Paris, France, Centre de Référence Déficits Immunitaires Héréditaires (CEREDIH), Paris, France, and the DEFI study group
| | - Klaus Warnatz
- Center for Chronic Immunodeficiency (CCI), University Medical Centre Freiburg and University of Freiburg, Freiburg, Germany
| | - Ilka Schulze
- Center for Chronic Immunodeficiency (CCI), University Medical Centre Freiburg and University of Freiburg, Freiburg, Germany
| | - Gerhard Kindle
- Center for Chronic Immunodeficiency (CCI), University Medical Centre Freiburg and University of Freiburg, Freiburg, Germany
| | - Taco W Kuijpers
- Dutch Working Party for Immunodeficiencies (WID), Amsterdam, The Netherlands
| | | | - Rachel T van Beem
- Medical Department Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
| | - David Guzman
- UCL Medical School Royal Free Campus and Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarita Workman
- UCL Medical School Royal Free Campus and Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Javier De Gracia
- Department of Pneumology, Hospital Universitari Vall d'Hebron, UAB, CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Torsten Witte
- Clinic for Immunology and Rheumatology, Medical University Hannover, Hannover, Germany
| | - Reinhold E Schmidt
- Clinic for Immunology and Rheumatology, Medical University Hannover, Hannover, Germany
| | - Jiri Litzman
- Department of Clinical Immunology and Allergology, Faculty of Medicine, Masaryk University and St Anne's University Hospital, Brno, Czech Republic
| | | | - Vojtech Thon
- Department of Clinical Immunology and Allergy, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michael Borte
- Children's Hospital, Municipal Hospital "St Georg," Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany
| | - Stephan Borte
- Children's Hospital, Municipal Hospital "St Georg," Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany; Translational Centre for Regenerative Medicine, University of Leipzig, Leipzig, Germany
| | - Dinakantha Kumararatne
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Conleth Feighery
- Department of Immunology, St James's Hospital Dublin and Trinity College Dublin, Dublin, Ireland
| | - Hilary Longhurst
- Department of Immunology, Barts Health NHS Trust, London, United Kingdom
| | - Matthew Helbert
- Central Manchester and Manchester Children's University Hospitals NHS Trust, Manchester, United Kingdom
| | | | - Anna Sediva
- Department of Immunology, 2nd School of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Bernd H Belohradsky
- Dr v. Haunersches Kinderspital, Ludwig Maximilians University, Munich, Germany
| | - Alison Jones
- Institute of Child Health/Great Ormond Street Hospital, London, United Kingdom
| | - Ulrich Baumann
- Immunology Unit, Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Isabelle Meyts
- Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | - Necil Kutukculer
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Per Wågström
- Department of Infectious Diseases, County Hospital Ryhov Jönköping, Jönköping, Sweden
| | - Nermeen Mouftah Galal
- Primary Immunodeficiency Clinic, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Joachim Roesler
- Department of Pediatrics, University Hospital Dresden, Dresden, Germany
| | - Evangelia Farmaki
- Pediatric Immunology and Rheumatology Referral Centre, First Department of Pediatrics, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Natalia Zinovieva
- Research and Clinical Centre for Pediatric Hematology, Oncology, Immunology, Moscow, Russia
| | - Peter Ciznar
- 1st Pediatric Department, Faculty of Medicine, Comenius University and Children University Hospital, Bratislava, Slovakia
| | - Efimia Papadopoulou-Alataki
- Aristotle University of Thessaloniki, Fourth Department of Pediatrics, Papageorgiou Hospital, Thessaloniki, Greece
| | - Kirsten Bienemann
- Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | - Zoya Panahloo
- Medical Science Department, CSL Behring, West Sussex, United Kingdom
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), University Medical Centre Freiburg and University of Freiburg, Freiburg, Germany; UCL Medical School Royal Free Campus and Royal Free Hospital NHS Foundation Trust, London, United Kingdom.
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Albin S, Cunningham-Rundles C. An update on the use of immunoglobulin for the treatment of immunodeficiency disorders. Immunotherapy 2014; 6:1113-26. [PMID: 25428649 PMCID: PMC4324501 DOI: 10.2217/imt.14.67] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For patients with significant antibody deficiencies, immunoglobulin therapy is the mainstay of treatment as it significantly reduces both the frequency and severity of infections. The formulations and delivery methods of immunoglobulin have evolved over time, and continued improvements have allowed for increased access to this effective medication. This review is an update on the current status of immunoglobulin therapy in immunodeficiency disorders, and discusses the mechanisms, forms and dosing, and indications for immunoglobulin replacement.
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Affiliation(s)
- Stephanie Albin
- Division of Allergy & Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Charlotte Cunningham-Rundles
- Division of Allergy & Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Maarschalk-Ellerbroek LJ, Hoepelman AIM, van Montfrans JM, Ellerbroek PM. The spectrum of disease manifestations in patients with common variable immunodeficiency disorders and partial antibody deficiency in a university hospital. J Clin Immunol 2012; 32:907-21. [PMID: 22526591 PMCID: PMC3443482 DOI: 10.1007/s10875-012-9671-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 02/14/2012] [Indexed: 11/26/2022]
Abstract
Background Common variable immunodeficiency disorders (CVIDs) represents a heterogeneous disease spectrum that includes recurrent infections and complications such as autoimmunity, inflammatory organ disease and an increased risk of cancer. A diagnostic delay is common in CVIDs patients. Purpose To determine the spectrum of clinical manifestations, immunological characteristics, and the time to diagnosis of 61 adult CVIDs and 18 patients with a partial antibody deficiency (SADNI and IgG subclass deficiency). Methods A retrospective cohort study was performed in patients who met the ESID/PAGID for CVIDs, IgG subclass deficiency and SADNI. Medical records were reviewed to obtain patient demographics, clinical and laboratory data. Results Infections were the main presentation of all antibody deficient patients and the number of patients with infections declined during IgG therapy. The development of bronchiectasis continued despite IgG therapy, as well as the development of autoinflammatory conditions. Non-infectious disease complications were present in 30% of CVIDs patients at the time of diagnosis and this increased to 51% during follow up despite IgG therapy. The most common complications were autoimmunity or lymphoproliferative disease. The median time to diagnosis was 10 years and in the patients with non-infectious complications the time to diagnosis was considerably longer when compared to the group of patients without complications (17.6 vs. 10.2 years, p = 0.026). Conclusion In contrast to the partial antibody deficiencies we found a considerable delay in the diagnosis of CVIDs, especially in those patients who were dominated by non-infectious complications, and thus increased awareness would be beneficial. Pulmonary and other complications may continue despite adequate IgG replacement therapy suggesting other causes responsible for these complications. Electronic supplementary material The online version of this article (doi:10.1007/s10875-012-9671-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L J Maarschalk-Ellerbroek
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
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Haddad E, Berger M, Wang ECY, Jones CA, Bexon M, Baggish JS. Higher doses of subcutaneous IgG reduce resource utilization in patients with primary immunodeficiency. J Clin Immunol 2011; 32:281-9. [PMID: 22193916 PMCID: PMC3305876 DOI: 10.1007/s10875-011-9631-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 12/04/2011] [Indexed: 11/26/2022]
Abstract
The recommended dose of IgG in primary immunodeficiency (PID) has been increasing since its first use. This study aimed to determine if higher subcutaneous IgG doses resulted in improved patient outcomes by comparing results from two parallel clinical studies with similar design. One patient cohort received subcutaneous IgG doses that were 1.5 times higher than their previous intravenous doses (mean 213 mg/kg/week), whereas the other cohort received doses identical to previous subcutaneous or intravenous doses (mean 120 mg/kg/week). While neither cohort had any serious infections, the cohort maintained on higher mean IgG dose had significantly lower rates of non-serious infections (2.76 vs. 5.18 episodes/year, P < 0.0001), hospitalization (0.20 vs. 3.48 days/year, P < 0.0001), antibiotic use (48.50 vs. 72.75 days/year, P < 0.001), and missed work/school activity (2.10 vs. 8.00 days/year, P < 0.001). The higher-dose cohort had lower health care utilization and improved indices of well being compared to the cohort treated with traditional IgG doses.
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Affiliation(s)
- Elie Haddad
- Department of Pediatrics, and Microbiology and Immunology, CHU Sainte-Justine, Université de Montréal, Montreal, QC Canada
| | - Melvin Berger
- CSL Behring LLC, 1020 First Avenue, P.O. Box 61501, King of Prussia, PA 19406-0901 USA
| | | | - Christopher A. Jones
- CSL Behring LLC, 1020 First Avenue, P.O. Box 61501, King of Prussia, PA 19406-0901 USA
- Present Address: Center for Clinical and Translational Science, University of Vermont College of Medicine, Burlington, VT USA
| | | | - Jeffrey S. Baggish
- CSL Behring LLC, 1020 First Avenue, P.O. Box 61501, King of Prussia, PA 19406-0901 USA
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van der Meer JWM, van Beem RT, Robak T, Deptala A, Strengers PFW. Efficacy and safety of a nanofiltered liquid intravenous immunoglobulin product in patients with primary immunodeficiency and idiopathic thrombocytopenic purpura. Vox Sang 2011; 101:138-46. [DOI: 10.1111/j.1423-0410.2011.01476.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Infection outcomes in patients with common variable immunodeficiency disorders: relationship to immunoglobulin therapy over 22 years. J Allergy Clin Immunol 2010; 125:1354-1360.e4. [PMID: 20471071 DOI: 10.1016/j.jaci.2010.02.040] [Citation(s) in RCA: 299] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 02/14/2010] [Accepted: 02/17/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Common variable immunodeficiency disorders (CVIDs) are the most common forms of symptomatic primary antibody failure in adults and children. Replacement immunoglobulin is the standard treatment, although there are few consistent data on optimal dosages and target trough IgG levels required for infection prevention. OBJECTIVE To provide data to support the hypothesis that each patient requires an individual dose of therapeutic immunoglobulin to prevent breakthrough infections and that efficacious trough IgG levels vary between patients. METHODS Data, collected prospectively from a cohort of 90 patients with confirmed CVIDs from 1 center over a follow-up period of 22 years, was validated and analyzed. Immunoglobulin doses had been adjusted in accordance with infections rather than to achieve a particular trough IgG level. Doses to achieve infection-free periods were determined and resultant trough levels analyzed. A smaller group of patients with X-linked agammaglobulinemia was analyzed for comparison. RESULTS Patients with a CVID had a range of trough IgG levels that prevented breakthrough bacterial infections (5-17 g/L); viral and fungal infections were rare. Doses of replacement immunoglobulin to prevent breakthrough infections ranged from 0.2 to 1.2 g/kg/mo. Those with proven bronchiectasis or particular clinical phenotypes required higher replacement doses. Patients with X-linked agammaglobulinemia showed a similar range of IgG levels to stay infection-free (8-13 g/L). CONCLUSION These data offer guidance regarding optimal doses and target trough IgG levels in individual patients with CVIDs with or without bronchiectasis and for particular clinical phenotypes. The goal of replacement therapy should be to improve clinical outcome and not to reach a particular IgG trough level.
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The Use of Immunoglobulin Therapy for Patients With Primary Immune Deficiency: An Evidence-Based Practice Guideline. Transfus Med Rev 2010; 24 Suppl 1:S28-50. [DOI: 10.1016/j.tmrv.2009.09.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Use of intravenous immunoglobulin and adjunctive therapies in the treatment of primary immunodeficiencies: A working group report of and study by the Primary Immunodeficiency Committee of the American Academy of Allergy Asthma and Immunology. Clin Immunol 2009; 135:255-63. [PMID: 19914873 DOI: 10.1016/j.clim.2009.10.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 10/07/2009] [Accepted: 10/14/2009] [Indexed: 11/22/2022]
Abstract
There are an expanding number of primary immunodeficiency diseases (PIDDs), each associated with unique diagnostic and therapeutic complexities. Limited data, however, exist supporting specific therapeutic interventions. Thus, a survey of PIDD management was administered to allergists/immunologists in the United States to identify current perspectives and practices. Among 405 respondents, the majority of key management practices identified were consistent with existing data and guidelines, including the provision of immunoglobulin therapy, immunoglobulin dosing and selective avoidance of live viral vaccines. Practices for which there are little specific data or evidence-based guidance were also examined, including evaluation of IgG trough levels for patients receiving immunoglobulin, use of prophylactic antibiotics and recommendations for complementary/alternative medicine. Here, variability applied to PIDD patients was identified. Differences between practitioners clinically focused upon PIDD and general allergists/immunologists were also identified. Thus, a need for expanded clinical research in PIDD to optimize management and potentially improve outcomes was defined.
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Urschel S, Kayikci L, Wintergerst U, Notheis G, Jansson A, Belohradsky BH. Common variable immunodeficiency disorders in children: delayed diagnosis despite typical clinical presentation. J Pediatr 2009; 154:888-94. [PMID: 19230900 DOI: 10.1016/j.jpeds.2008.12.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 10/08/2008] [Accepted: 12/05/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To characterize common variable immunodeficiency disorder (CVID) in childhood. STUDY DESIGN We retrospectively investigated clinical findings in 32 children with primary CVID by questionnaire and file review. RESULTS Clinical presentation included recurrent or chronic respiratory tract infections (88%), sinusitis (78%), otitis media (78%), and intestinal tract infections (34%), mainly with encapsulated bacteria. Meningitis was found in 25%, sepsis in 16%, and pyelonephritis in 16% of patients. Poliomyelitis after vaccination occurred in 2 patients and opportunistic infections occasionally. Allergic disorders were present in 38%, and autoimmune disease in 31% of patients. Eighty percent of the patients underwent surgical procedures because of recurrent infections. Growth retardation was seen in 28% of patients, and 16% showed retarded mental development. Bronchiectasis developed in 34%, and lymphoid proliferative disease in 13%. Incidence of allergic and autoimmune diseases was increased in first-degree relatives with normal immunologic findings. Mean time between symptoms and induction of immunoglobulin substitution therapy was 5.8 years (0.2-14.3). CONCLUSIONS CVID in children presents with comparable symptoms and disorders as in adults. We found a significant influence on growth and development. The marked delay of diagnosis may be due to overlap with common pediatric disorders, while also reflecting insufficient awareness of these disorders.
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Affiliation(s)
- Simon Urschel
- Pediatric Immunology and Infectious Diseases, University Children's Hospital, Ludwig Maximilians University, Munich, Germany.
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13
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Sánchez-Ramón S, Radigan L, Yu JE, Bard S, Cunningham-Rundles C. Memory B cells in common variable immunodeficiency: clinical associations and sex differences. Clin Immunol 2008; 128:314-21. [PMID: 18620909 DOI: 10.1016/j.clim.2008.02.013] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 02/11/2008] [Accepted: 02/25/2008] [Indexed: 12/21/2022]
Abstract
Common variable immunodeficiency (CVID) is a heterogeneous syndrome characterized by impaired antibody responses, recurrent infections, inflammatory, autoimmune and malignancy-related conditions. We evaluated the relationship between memory B cell phenotype, sex, age at diagnosis, immunologic and clinical conditions in 105 CVID subjects from one medical center. Reduced numbers of switched memory B cells (cutoff <or=0.55% of B cells) were an independent risk factor of granulomas, autoimmune diseases and splenomegaly (p<0.001). Not previously noted, CVID females had significantly more switched memory cells (p=0.007) than males. Splenectomized subjects did not have fewer IgM memory B cells and these numbers were not related to the development of lung disease, as previously proposed. Lower baseline serum IgG was an independent predictor of pneumonia (p=0.007) and severe infections (p=0.001). We conclude that outcomes in CVID depend on an interplay of factors including sex, numbers of switched memory B cells, and baseline serum IgG and IgA levels.
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Affiliation(s)
- Silvia Sánchez-Ramón
- Department of Medicine, Pediatrics and Immunobiology Center, Mount Sinai Medical School, New York, NY 10029, USA
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Busse PJ, Farzan S, Cunningham-Rundles C. Pulmonary complications of common variable immunodeficiency. Ann Allergy Asthma Immunol 2007; 98:1-8; quiz 8-11, 43. [PMID: 17225714 DOI: 10.1016/s1081-1206(10)60853-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To review pulmonary complications of common variable immunodeficiency (CVID) and summarize data available on the use of replacement antibody treatment to protect against lung changes. DATA SOURCES Relevant articles regarding CVID and pulmonary disease identified from PubMed and reference lists of review articles. STUDY SELECTION Key articles were selected by the authors. RESULTS Patients with CVID often develop acute sinopulmonary infections that can lead to chronic airway inflammation, which can produce substantial morbidity and mortality. Replacement immunoglobulin treatment significantly reduces the reoccurrence of lower airway infections, but the effect on the development of chronic lung damage is not yet clear. Screening examinations, such as pulmonary function testing and high-resolution computed tomography of the chest, can be used to evaluate pulmonary status. Patients with abnormal findings may benefit from more aggressive treatment, including larger doses of immune globulin and the use of prophylactic antibiotics. CONCLUSIONS Pulmonary complications present a significant comorbidity in CVID; monitoring may indicate which patients require more aggressive treatment.
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Affiliation(s)
- Paula J Busse
- Allergy and Immunology, Mt Sinai Hospital, New York, New York 10029, USA
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Ochs HD, Gupta S, Kiessling P, Nicolay U, Berger M. Safety and efficacy of self-administered subcutaneous immunoglobulin in patients with primary immunodeficiency diseases. J Clin Immunol 2007; 26:265-73. [PMID: 16783465 DOI: 10.1007/s10875-006-9021-7] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Intravenous immunoglobulin (IVIg) infusions at 3-4 week intervals are currently standard therapy in the United States for patients with primary immune deficiency diseases (PIDD). To evaluate alternative modes of immunoglobulin administration we have designed an open-label study to investigate the efficacy and safety of a subcutaneously administered immunoglobulin preparation (16% IgG) in patients with PIDD. After their final IVIg infusion, 65 patients entered a 3-month, wash-in/wash-out phase, designed to bring patients to steady-state with subcutaneously administered immunoglobulin. This was followed by 12 months of weekly SCIg infusions, at a dose determined in a pharmacokinetic substudy to provide noninferior intravascular exposure. This resulted in a mean weekly dose of 158 mg/kg, calculated to equal 137% of the previous intravenous dose. Two patients (4%) each reported 1 serious bacterial infection (pneumonia), an annual rate of 0.04 per patient-year. There were 4.43 infections of any type per patient-year. Mean trough serum IgG levels increased from 786 to 1040 mg/dL during the study, a mean increase of 39%. The most frequent treatment-related adverse event was infusion-site reaction, reported by 91% of patients; this was predominantly mild or moderate, and the incidence decreased over time. No treatment-related serious adverse events were reported. We conclude that subcutaneous administration of 16% SCIg is a safe and effective alternative to IVIg for replacement therapy of PIDD.
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Affiliation(s)
- Hans D Ochs
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98107, USA.
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Affiliation(s)
- S Jolles
- Department of Clinical Immunology, Royal Free Hospital London, UK.
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Khalili B, Montanaro A. Cough and weight loss in a patient with cystic fibrosis. Ann Allergy Asthma Immunol 2005; 94:333-40. [PMID: 15801243 DOI: 10.1016/s1081-1206(10)60984-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Barzin Khalili
- Oregon Health Science University, Buffalo, Oregon 97239, USA.
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Favre O, Leimgruber A, Nicole A, Spertini F. Intravenous immunoglobulin replacement prevents severe and lower respiratory tract infections, but not upper respiratory tract and non-respiratory infections in common variable immune deficiency. Allergy 2005; 60:385-90. [PMID: 15679727 DOI: 10.1111/j.1398-9995.2005.00756.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although the dose of 400 mg/kg body weight intravenous immunoglobulins (IVIG) every 3-4 weeks is now standard for treating patients with common variable immune deficiency, studies demonstrating its long-term benefits over low 200 mg/kg dose and its effects on infectious subsets (upper vs lower respiratory vs non-respiratory infections) are rare. METHODS All patients from a single center with the diagnosis of common variable immune deficiency and whose clinical chart was available during three successive therapeutic periods [a pre-IVIG replacement period, a low-dose (200 mg/kg every 3 weeks) and a standard-dose replacement period (400 mg/kg every 3 weeks)] were screened retrospectively. RESULTS Seven patients followed up for a total of 116 patient-years over the three defined periods of observation were recruited. When compared with low-dose therapy, standard-dose intravenous immunoglobulin therapy raised trough IgG levels from 4.3 to 6.5 g/l and significantly decreased the overall frequency of infections, with marked effects on lower respiratory tract and severe infection number. In contrast, non-respiratory and upper respiratory infections were, in comparison, resistant to therapy. CONCLUSIONS Overall, these data support the use of standard-dose 400 mg/kg intravenous immunoglobulin therapy, despite the high cost, to raise trough IgG levels to 5-7 g/l, but underlines that some categories of infectious events (non-respiratory, upper respiratory) may need parallel surgical or pharmacological approaches to be optimally prevented or treated.
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Affiliation(s)
- O Favre
- Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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de Gracia J, Vendrell M, Alvarez A, Pallisa E, Rodrigo MJ, de la Rosa D, Mata F, Andreu J, Morell F. Immunoglobulin therapy to control lung damage in patients with common variable immunodeficiency. Int Immunopharmacol 2004; 4:745-53. [PMID: 15135316 DOI: 10.1016/j.intimp.2004.02.011] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2004] [Revised: 02/17/2004] [Accepted: 02/25/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Lung damage progression is the most frequent condition in patients with common variable immunodeficiency (CVID). Appropriate immunoglobulin dose adjustments and follow-up guidelines to evaluate this have not been well established. OBJECTIVE To assess the evolution of lung damage once stable residual serum levels of IgG over 600 mg/dl had been achieved. METHODS A prospective study was conducted in 24 adult patients consecutively diagnosed with CVID, with no previous intravenous immunoglobulin (IVIG) treatment. IVIG dose, total serum IgG level, bacterial infection rate, pulmonary function tests (PFTs) and high resolution computed tomography (HRCT) of the thorax were monitored over 2 years. Moreover, outcome data were determined by measurement of chronic pulmonary disease (CPD). RESULTS IVIG dose variability (205-372 mg/kg/21 days) to obtain the required serum IgG levels was determined. Patients with CPD needed higher doses than those without CPD (p=0.045). A significant reduction in severe and mild infections/patient-year was observed during treatment. Overall, there were no changes in PFTs and HRCT scores in patients without CPD, but both improved in patients with CPD. An increase of over 15% in overall HRCT score was detected in two patients without evidence of impairment in either clinical status or PFT values. CONCLUSIONS Residual levels of total IgG over 600 mg/dl may help prevent progression of lung damage in patients with CVID. Levels of IgG, clinical manifestations and PFTs seem sufficient for routine follow-up. HRCT examination of the thorax, at least biennially, may help to identify patients in whom lung injury is progressing even though they may remain symptom-free and with stable PFTs.
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Affiliation(s)
- Javier de Gracia
- Department of Pneumology, Hospital Universitari Vall d'Hebron, Roger de Flor 235 bajos 2(a), 08025 Barcelona, Spain.
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