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Singer M, Torres A, Heinz CC, Weißmüller S, Staus A, Kistner S, Jakubczyk K, Häder T, Langohr P, Wartenberg-Demand A, Schüttrumpf J, Vincent JL, Welte T. The immunomodulating activity of trimodulin (polyvalent IgM, IgA, IgG solution): a post hoc analysis of the phase II CIGMA trial. Crit Care 2023; 27:436. [PMID: 37946226 PMCID: PMC10634136 DOI: 10.1186/s13054-023-04719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The phase II CIGMA trial performed in 160 patients with severe community-acquired pneumonia (sCAP) found treatment with trimodulin (human polyvalent immunoglobulin [Ig]: ~ 23% IgM, ~ 21% IgA, ~ 56% IgG) was associated with a lower mortality in those patients with elevated baseline serum levels of C-reactive protein (CRP) and/or subnormal IgM. METHODS In this post hoc analysis, the pharmacodynamic effects of trimodulin treatment (182.6 mg/kg/day for 5 days) were investigated on Ig replenishment, cellular markers of inflammation (absolute neutrophil [ANC] and lymphocyte [ALC] count, neutrophil-to-lymphocyte ratio [NLR]), and soluble markers of inflammation (procalcitonin [PCT] and CRP). The impact of these pharmacodynamic effects on mortality was also evaluated. RESULTS Compared with healthy subjects, baseline serum levels of IgM, IgG, and ALC were significantly lower, and ANC, NLR, PCT and CRP significantly higher in sCAP patients (p < 0.0001). Low Ig concentrations increased with trimodulin. Normalization of ANC (analysis of variance [ANOVA] p = 0.016) and PCT (ANOVA p = 0.027) was more rapid with trimodulin compared with placebo. These and other effects were more evident in patients with low baseline IgM levels. Normalization of PCT and CRP levels was both steadier and faster with trimodulin treatment. In patients with low baseline ALC, trimodulin was associated with a lower 28-day all-cause mortality rate (14.5% vs 32.1% in placebo, p = 0.043) and more ventilator-free days ([VFD]; median VFD: 3.5 vs 11 in placebo, p = 0.043). These numerical differences were greater if baseline IgM was also low (low ALC, low IgM: 8.1% mortality vs 34.1% placebo, p = 0.006; 3 VFD vs 15 VFD, p = 0.009, respectively). Results were consistent in patients with high baseline CRP (low ALC, high CRP: 10.9% mortality vs 34.1% placebo, p = 0.011). CONCLUSIONS This post hoc pharmacodynamic analysis of a blinded phase II trial suggests that trimodulin compensates for, and more rapidly modifies, the dysregulated inflammatory response seen in sCAP patients. Trimodulin was associated with significantly lower mortality and more VFD in subgroups with high CRP and low ALC. This effect was particularly marked in patients who also had low baseline IgM values. These findings require confirmation in prospective trials.
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Affiliation(s)
- Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Antoni Torres
- Hospital Clínic, Servei de Pneumologia I Allèrgia Respiratòria, Catedràtic de Medicina, Universitat de Barcelona, Barcelona, Spain.
- IDIBAPS, ICREA, CIBER de Enfermedades Respiratorias, Barcelona, Spain.
| | - Corina C Heinz
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | | | - Thomas Häder
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
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Luchsinger V, Lizama L, Garmendia ML, Tempio F, Ruiz M, Pizarro R, Rossi P, Huenchur L, Moreno C, López M, Ampuero S, Larrañaga C, Avendaño LF. Immunoglobulins concentration and B cell counts as severity markers in adult community-acquired pneumonia: Cross sectional study. Medicine (Baltimore) 2020; 99:e22390. [PMID: 33157914 PMCID: PMC7647610 DOI: 10.1097/md.0000000000022390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Community-acquired pneumonia (CAP) is a worldwide cause of morbidity and mortality. Immunoglobulins (Igs) and B cells quantification studies in CAP are few and show discrepancies. Serum IgA acts as a powerful natural anti-inflammatory factor, but its role in the CAP has not yet been defined. The highly sensitive xMAP Luminex technique allows better immunoglobulins quantification. The aim of this study was to analyze the relation between clinical severity and circulating Igs and B cells in adults with CAP.Igs (M, A, G1, G2, G3, and G4) and B cells were quantified in peripheral blood of 190 Chilean patients ≥18 years old hospitalized for CAP and in 21 adults without respiratory disease, using xMAP Luminex and flow cytometry, respectively. Clinical history was recorded and PSI and CURB-65 scores were calculated for evaluation of clinical severity.The total IgM, IgG2 and total IgG levels were lower in CAP than in asymptomatic adults (P < .05). No significant differences of Igs levels were found between patients classified as severe and mild by PSI and CURB-65 scores. Fatal cases had higher levels of IgA (P < .05). No differences in CD19 B cells frequency was found between CAP and asymptomatic adults (P = .40). In PSI severe cases, CD19 B cells were significantly lower than in mild cases (P = .008). No differences were found in CURB-65 severe and mild groups (P = .11). In fatal cases (11/82) group, CD19 B cells frequency was lower than in 71 survivors (P = .2). No differences in memory B lymphocytes were detected between asymptomatic and CAP adults, severe and mild patients, survivors and fatal cases (P > .05).Serum IgA levels were significantly higher in fatal CAP cases, raising it as a potential biomarker for severe disease considering its relatively universal availability. In PSI severe patients, B cells showed lower levels and could have a role on its physiopathology. Finding new markers rooted in physiopathology could improve the possibility of scoring severe CAP cases. Luminex technology showed promising quantification serum Igs.
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Affiliation(s)
- Vivian Luchsinger
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
| | - Luis Lizama
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
| | | | - Fabián Tempio
- Programa de Inmunología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
- Instituto Milenio de Inmunología e Inmunoterapia, Facultad de Medicina
| | | | | | | | | | - Cristian Moreno
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
| | - Mercedes López
- Programa de Inmunología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
- Instituto Milenio de Inmunología e Inmunoterapia, Facultad de Medicina
| | - Sandra Ampuero
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
| | - Carmen Larrañaga
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
| | - Luis Fidel Avendaño
- Programa de Virología, ICBM: Programa de Virología, ICBM, Facultad de Medicina
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