Adverse reactions in selected patients following intravenous infusions of gamma globulin

Acute renal failure associated with immunoglobulin therapy

Four cases of acute renal failure induced by intravenous immunoglobulin are presented, and the literature on the subject is reviewed. The clinical course varies from asymptomatic serum creatinine elevation to anuric renal failure occurring within days of the institution of therapy, followed by the rapid recovery of renal function after termination of therapy. The renal histology demonstrates severe tubular vacuolization with cellular swelling and preservation of the brush border. Glomerular endothelial, mesangial, and epithelial cells also may demonstrate swelling and vacuolization. There is no evidence for inflammatory or immune complex-mediated etiologies. The immunoglobulins or carbohydrate additives in the preparations appear to have a unique and reversible effect on the glomerular and tubular cell function.

Clinical immunology and infectious diseases

Without the application of immunology, understanding of the pathogenesis and pathophysiology of infectious diseases would be severely retarded. The development new vaccines for the prevention of infectious diseases has been based on new immunologic findings. Immunodiagnostic modalities have provided for the growth of diagnostic techniques for infectious diseases. Clinical immunology also has laid the groundwork for immunotherapies using the old intravenous immunoglobulin preparations and the new monoclonal antibodies, cytokines, and interferons.

Use of intravenous immune globulin therapy: an overview

The intravenous immune globulin (IGIV) preparations are reviewed with respect to method of preparation, pharmacokinetics, clinical uses (with emphasis on the labeled indications), and adverse reactions; a brief review of the immune system also is provided. IGIV preparations are approved for the treatment of hypogammaglobulinemia, recurrent bacterial infections due to B-cell chronic lymphocytic leukemia, and idiopathic thrombocytopenic purpura (ITP). The mechanism of action in the first two indications is passive replacement of antibodies, but in ITP the mechanism is not clearly established. The clinical literature on the use of IGIV for these indications is summarized. In patients with ITP, platelet counts return to safe levels and the number of infections is reduced in patients with primary humoral immunodeficiency treated with IGIV. The use of IGIV in pregnant women and premature infants is controversial. Adverse reactions are primarily related to infusion rate, activation of complement, and anaphylactic reactions to a component of the product. There is minimal to no risk of viral transmission with IGIV therapy. IGIV also has been administered safely on an outpatient or homecare basis. This has led to a feeling of greater control by patients over their chronic illness. Other uses of IGIV are under investigation. As our understanding of the immune system and the pharmacology of immune globulin increases, the uses of IGIV will expand.

Allergic histories and reactions of patients treated with digoxin immune Fab (ovine) antibody. The Digibind Study Advisory Panel

Seven hundred seventeen adult patients with life-threatening digitalis intoxication were treated with Fab fragments of ovine antidigoxin immunoglobulin G (IgG). Results of the efficacy of treatment and adverse effects were collected with standard report forms. Eighty-two (11%) of the patients were recorded as having histories of allergy (71 patients) and/or asthma (11 patients). Of the "allergic" subjects, 35 described reactions to antibiotics, 19 to other medications, 3 to foods, and 2 to pollens; in 12 subjects the etiologic agent was not specified. Six subjects had adverse reactions that were probably or possibly due to allergy to components of the antibody preparation. Of these 4 (5%; 95% confidence interval (Cl) 1.8% to 12%) occurred in the 82 subjects with histories of allergy or asthma and 3 (9%; 95% Cl 1.8% to 23%) of these occurred in the 35 persons with histories of allergy to an antibiotic. In contrast, only 2 (0.3%; 95% Cl 0.04% to 1.1%) similar reactions occurred in the 635 subjects with no histories of allergy or asthma. All reactions responded to symptomatic treatment. The authors conclude that treatment of digitalis intoxication with ovine antidigoxin IgG-Fab (Digibind) is generally well tolerated and allergic reactions are rare. However, there is a significantly increased risk of reactions in patients with histories of allergy or asthma.

Anti-IgA antibodies in selective IgA deficiency and in primary immunodeficient patients treated with gamma-globulin

Sera from 106 blood donors, 40 patients with primary immunodeficiencies (ID) treated with gamma-globulin, and 46 patients with selective IgA deficiency were analyzed by an enzyme-linked immunosorbent assay for anti-IgA antibodies. Increased levels of antibodies to IgA were found in 5.6% of the blood donors, 17.5% of the ID patients, and 36.8% of the isolated IgA deficiencies. The percentage was higher in patients with IgA and IgG2 deficiencies (50%). The percentage of patients having increased levels of anti-IgA antibodies was similar to the total prevalence of the 10 other autoantibodies studied. These anti-IgA antibodies were mainly of the IgG class, except from one blood donor with IgM antibodies, and two patients, one with isolated IgA deficiency and the other with common variable immunodeficiency who had anti-IgA antibodies of the IgE class. The latter patient developed a near fatal anaphylactic reaction when intravenous gamma-globulin was administered. Most of the patients with severe adverse reactions to gamma-globulin did not present anti-IgA antibodies. Our data suggest that at least in some immunodeficient patients the elevated amounts of anti-IgA antibodies are not related to the administration of exogenous IgA. The importance of measuring anti-IgA antibodies of the IgG and IgE isotypes in IgA-deficient patients as well as in patients in treatment with gamma-globulin is emphasized.

Disposition of an immunoglobulin intravenous preparation in very low birth weight neonates

To assess the disposition, tolerance, and toxicity of an intravenous preparation of immunoglobulin (IGIV) in very low birth weight (VLBW) neonates, we administered single doses of 500 or 750 mg/kg to 20 neonates with birth weights between 750 and 1500 g during the first week of life. The infusion of this product was well tolerated. Modest changes in hemoglobin, hematocrit, and total hemolytic complement occurred as expected. Hepatic toxic effects were not detected. Mean peak IgG concentrations were 1564 and 1316 mg/dL for the high-dose and low-dose groups, respectively. Mean IgG concentrations were very similar for both groups on postinfusion days 1, 4, 7, 14, 21, and 28. IgG concentrations remained above 300 mg/dL in seven of 10 infants in each group by day 21, and in six of the high-dose group and seven of the low-dose group by day 28. Mean elimination half-lives were 22.6 and 22.8 days in the high-dose and low-dose groups, respectively. These data provide a basis for assessment of potential efficacy of IGIV in the prevention of late-onset infection in VLBW neonates.

Protooncogene expression in peripheral blood mononuclear cells from patients with systemic lupus erythematosus as an indicator of the disease activity

In the present study, we examined the various protooncogene expressions in PBMC (peripheral blood mononuclear cell) of systemic lupus erythematosus (SLE) patients to determine if they could be an indicator for the disease activity. We divided SLE patients into "very active," "active," and "remitting" states according to the clinical symptoms in addition to the laboratory data peculiar to SLE. In addition, we determined the amount of circulating immune complex (IC) as one of the representative laboratory indicators for the disease activity. We found a positive correlation with either c-myc or c-myb expression and the amounts of IC and clinical disease activity. The degree of c-myc and c-myb expression was significantly reduced along with or prior to the amelioration of clinical symptoms and improvement as determined by laboratory data under treatment with prednisolone and/or azathioprine administration. The degree of c-myc and c-myb gene expression had no direct relation to the presence of particular clinical sign(s) or autoantibody. The expression of the c-raf gene was found in SLE and other systemic autoallergic patients although it showed no correlation with the disease activity. No significant expression of c-src, c-ras, c-fos, c-fgr, c-fps, c-fes, c-fms, c-yes, c-rel, c-abl, c-mos, c-sis, and c-erb B genes was found in the patients. c-myc and c-myb expression as having pathogenic and clinical significance is discussed.

Intravenous immune globulin: dosage and administration

Intravenous immune globulin (IV-IgG) is approved for use in substitution therapy of immunodeficiency syndromes and treatment of idiopathic thrombocytopenic purpura (ITP). The initial dose for substitution therapy is 0.2 g/kg body weight repeated monthly. If necessary, the dose may be increased to 0.3 g/kg and the frequency to every 2-3 weeks. The approved dosage for ITP is 0.4 g/kg daily for 2 to 5 consecutive days. Repeat doses of 0.4 g/kg have been used as maintenance therapy. The initial infusions of IgG to immunodeficient patients who have not been treated during the previous 8 weeks or never treated at all should proceed with caution. These patients are at risk of potentially serious complement-mediated adverse reactions. Adverse reactions due to IgG administration are less frequent and less severe for patients with ITP. Currently available preparations are contraindicated in patients with a selective IgA deficiency and detectable IgA antibodies.

C1 esterase inhibitor deficiency in X-linked hypogammaglobulinaemia: an anomaly fostering anaphylactoid reactions following intramuscular gammaglobulin administration

A patient with apparent X-linked agammaglobulinaemia was found to be inordinately susceptible to anaphylactoid reactions to intramuscular injections of gammaglobulin. The patient was found also to have low levels of C1 esterase inhibitor (C1 INH). The possibility that the C1 INH deficiency and in this patient, whether genetic or acquired, fostered the susceptibility to the production of anaphylactoid reactions after gammaglobulin injections urges further studies of the association of C1 INH deficiency and anaphylactoid reactions to gammaglobulin injections. The possibility that C1 INH levels like C1q levels may be low in hypogammaglobulinaemic patients as a consequence of increased catabolism of this regulator of the complement system when IgG levels are low is considered.

Dietary bovine antigens and immune complex formation after intravenous immunoglobulin in common varied immunodeficiency

Previously we have shown that the sera of hypogammaglobulinemic patients may contain large amounts of antigenically intact foreign protein of dietary origin, presumably due to the absence of an adequate gastrointestinal secretory immune barrier. In these studies we show that the intravenous infusion of immunoglobulin in these patients may result in high levels of immune complexes postinfusion and that at least one constituent of these complexes is likely to be bovine casein.

Corticosteroids for prevention of adverse reactions to intravenous immune serum globulin infusions in hypogammaglobulinemic patients

Severe adverse reactions to intravenous immune serum globulin occurred repeatedly in four of 10 hypogammaglobulinemic patients. Treatment-limiting symptoms included fever, chills, headache, hypertension, and chest pain. Pretreatment of patients with hydrocortisone immediately prior to infusion prevented subsequent adverse reactions and permitted these patients to receive immune serum globulin intravenously.

Treatment of AB deficiencies

The objective of this study was to compare serum immunoglobulin levels and the clinical status of patients with primary immune deficiency who received an intravenous immunoglobulin (IVIG) (pH 4.0) preparation for 1 year with results previously obtained when the same patients received intramuscular immunoglobulin (IMIG). During the IVIG treatment year, increased serum immunoglobulin levels, shorter duration of certain infectious disorders, reduced antibiotic use, ans improved rheumatoid symptoms were observed. The actual benefit of IVIG therapy could not be established until after the sixth months, since illness was even further reduced during the second 6 months of treatment. Other clinical observations are evaluated in the 2 groups.

Intravenous immunoglobulins: pharmacological aspects and therapeutic use

The requirements for a present-day IVIG preparation are outlined. These are mainly: fully preserved activities of the recognition and effector functions of the IgG molecule, a normal subclass distribution, and a normal half-life after infusion. The therapeutic uses of IVIG preparations are discussed as follows: Antibody substitution in cases of generalized or partial antibody deficiency in immune-compromised patients. These include the following diseases: hypogammaglobulinemia (congenital and acquired, including the neonates); drug-induced and viral immunosuppression. Antibody substitution in cases of selective antibody deficiency in otherwise immune-competent patients. These include acute cases of consumptive antibody deficiencies of the Jarisch-Herxheimer reaction type; in particular, chronic inflammations which apparently involve ineffective immune responses in which the organism is unable to build up sufficient amounts of antibodies with the required partial specificity, which is indispensable for overcoming the disease. Modulation of the immune system by Ig-Ig interactions (mainly idiotype-anti-idiotype interactions) and Ig-Fc-receptor interactions, as it is known from the RES blockade during IVIG treatment of idiopathic thrombocytopenic purpura.

Prediction, prevention, and mechanism of early (anaphylactic) antivenom reactions in victims of snake bites

Victims of snake bites are often subjected to cutaneous or conjunctival hypersensitivity testing before being given antivenom. None of 12 early (anaphylactic) reactions was predicted by these tests in 25 Nigerian and Thai patients. The incidence and severity of early reactions was the same whether antivenom was given by intravenous injection over 10 minutes or diluted and given as an intravenous infusion over 30 minutes. Although antivenom activated complement in vitro, there was no evidence of complement activation or formation of immune complexes in patients bitten by snakes who were treated with antivenom, whether or not they developed early reactions. Higher doses of antivenom might induce the complement activation and formation of immune complexes (aggregates) that have been observed during the clinically more severe reactions associated with homologous immunoglobulin treatment.