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Perry WA, Martino AEA, Garcia MR, Chow JK, Snydman DR. Sex- and age-based comparison of serum immunoglobulins following liver transplantation. Transpl Immunol 2023; 78:101826. [PMID: 36934899 PMCID: PMC10192009 DOI: 10.1016/j.trim.2023.101826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Over a quarter of organ transplant recipients have low immunoglobulin levels in their early post-transplant course, which is associated with increased risk of infection and mortality. Although immunoglobulin level varies by sex among healthy individuals, it is unknown how such differences are affected by transplant-related immunosuppression. This study compared post-liver transplant immunoglobulin G (IgG) between sexes at varying ages. METHODS Serum specimens from a prospective cohort of 130 liver transplant recipients were analyzed. IgG was measured at time of transplant and from one-month post-transplant samples. Post-transplant IgG was compared between sexes using multivariable linear regression. Four age and sex categories were created (women<50, women≥50, men<50, men≥50) and the model repeated with this as the explanatory variable. The relationship between sex hormone concentrations and post-transplant IgG was also explored. Infection type and incidence were examined within groups. RESULTS The cohort included 99 men, 31 women (mean age 53). In adjusted linear regression, post-transplant IgG was not significantly different by sex (p = 0.92). However, when broken into four categories by age and sex, the contrast in IgG levels between younger versus older patients was strikingly greater among women than among men. An interaction term including age and sex was statistically significant (p = 0.03). The combined age-sex categorical variable was also significantly associated with post-transplant IgG (p = 0.01). Finally, an association was identified between baseline estradiol level and post-transplant change in IgG (p = 0.04). CONCLUSIONS Sex and age have an important relationship with post-transplant IgG with older women demonstrating lowest concentrations. Immunoglobulin levels have previously demonstrated association with post-transplant outcomes.
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Affiliation(s)
- Whitney A Perry
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA.
| | | | | | - Jennifer K Chow
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA
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2
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van den Hoogen P, Huibers MMH, van den Dolder FW, de Weger R, Siera-de Koning E, Oerlemans MIF, de Jonge N, van Laake LW, Doevendans PA, Sluijter JPG, Vink A, de Jager SCA. Elevated Plasma Immunoglobulin Levels Prior to Heart Transplantation Are Associated with Poor Post-Transplantation Survival. BIOLOGY 2022; 12:biology12010061. [PMID: 36671753 PMCID: PMC9855413 DOI: 10.3390/biology12010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Cardiac allograft vasculopathy (CAV) and antibody-mediated rejection are immune-mediated, long-term complications that jeopardize graft survival after heart transplantation (HTx). Interestingly, increased plasma levels of immunoglobulins have been found in end-stage heart failure (HF) patients prior to HTx. In this study, we aimed to determine whether increased circulating immunoglobulin levels prior to transplantation are associated with poor post-HTx survival. Pre-and post-HTx plasma samples of 36 cardiac transplant recipient patients were used to determine circulating immunoglobulin levels. In addition, epicardial tissue was collected to determine immunoglobulin deposition in cardiac tissue and assess signs and severity of graft rejection. High levels of IgG1 and IgG2 prior to HTx were associated with a shorter survival post-HTx. Immunoglobulin deposition in cardiac tissue was significantly elevated in patients with a survival of less than 3 years. Patients with high plasma IgG levels pre-HTx also had significantly higher plasma levels after HTx. Furthermore, high pre-HTX levels of IgG1 and IgG2 levels were also significantly increased in patients with inflammatory infiltrate in CAV lesions. Altogether the results of this proof-of-concept study suggest that an activated immune response prior to transplantation negatively affects graft survival.
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Affiliation(s)
- Patricia van den Hoogen
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Manon M. H. Huibers
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Floor W. van den Dolder
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Roel de Weger
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Erica Siera-de Koning
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Marish I. F. Oerlemans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Linda W. van Laake
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Netherlands Heart Institute (NLHI), 3511 EP Utrecht, The Netherlands
- Centraal Militair Hospitaal (CMH), 3584 EZ Utrecht, The Netherlands
| | - Joost. P. G. Sluijter
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Aryan Vink
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Saskia C. A. de Jager
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
- Laboratory of Translational Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Correspondence:
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3
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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Anand P. Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies. ACTA ACUST UNITED AC 2021; 27:1066-1104. [PMID: 34623105 DOI: 10.1212/con.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised. RECENT FINDINGS Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population. SUMMARY A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.
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Yang H, Wu K, Zhang H, Owyang Q, Miao Y, Gu F, Hu N, Zou K, Sheng J, Li J, Zheng P, Liu Y, Li J, Wang X, Wu Y, Yuan Y, Chen C, Pang Y, Cui M, Qian J. IgA, albumin, and eosinopenia as early indicators of cytomegalovirus infection in patients with acute ulcerative colitis. BMC Gastroenterol 2020; 20:294. [PMID: 32891125 PMCID: PMC7487863 DOI: 10.1186/s12876-020-01434-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 08/21/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection can significantly complicate and worsen the condition of acute severe ulcerative colitis (UC) patients. We aimed to explore the predictive risk factors to prevent and identify CMV infection at an early stage in acute UC patients. METHODS A total of 115 moderate-to-severe active UC patients from 17 hospitals throughout China were enrolled. Active CMV infection was diagnosed by one of the following: CMV pp65 antigens, CMV IgM antibodies or CMV DNA. We identified the independent risk factors by multivariate analyses. RESULTS A total of 64 of 115 active UC patients had active CMV infection. Compared to the non-CMV-infected patients, the CMV-infected patients had a tendency to be male and to exhibit abdominal pain; fever; oral ulcers; eosinopenia; low albumin, immunoglobulin (Ig) A, IgM, and IgG levels; increased high-sensitivity C-reactive protein (hsCRP) levels; hyponatremia; pancolonic lesions; initial onset type; severe activity; and glucocorticoid (high-dose) and immunosuppressive agent use (P < 0.05). In further multivariate analyses, the use of high-dose glucocorticoids (OR 13.55, 95% CI 2.49-73.61, P < 0.01) and immunosuppressive agents (OR 11.23, 95% CI 1.05-119.99, P = 0.04) were independent risk factors for CMV infection. A decrease eosinophil and albumin levels were risk factors for CMV infection. With every 0.1*10^9/L decrease in the peripheral blood eosinophil level or 1 g/L decrease in the serum albumin level, the risk for CMV infection in UC patients increased by 5.21-fold (1/0.192) or 1.19-fold (1/0.839), respectively. CONCLUSIONS High-dose glucocorticoid and immunosuppressive agent treatment significantly increase the risk of CMV infection, and correcting eosinopenia and low albumin levels may help prevent CMV infection in UC patients.
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Affiliation(s)
- Hong Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, P.R. China
| | - Kaichun Wu
- Department of Gastroenterology, Xijin Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hongjie Zhang
- Department of Gastroenterology, Jiangsu Province Hospital, Nanjing, China
| | - Qin Owyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Yinglei Miao
- Department of Gastroenterology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Fang Gu
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Naizhong Hu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kaifang Zou
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jianqiu Sheng
- Department of Gastroenterology, General Hospital of Beijing Military Region, Beijing, China
| | - Jin Li
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ping Zheng
- Department of Gastroenterology, Shanghai General Hospital, Shanghai, China
| | - Yulan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China
| | - Junxia Li
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
| | - Xiaodi Wang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Yongdong Wu
- Department of Gastroenterology, Beijing Friendship Hospital of Capital Medical University, Beijing, China
| | - Yaozong Yuan
- Department of Gastroenterology, Ruijin Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chunxiao Chen
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang University, Beijing, China
| | - Yanhua Pang
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Beijing, China
| | - Meihua Cui
- Department of Gastroenterology, Aerospace Central Hospital, Beijing, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, P.R. China.
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, P.R. China.
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6
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Peter HH, Ochs HD, Cunningham-Rundles C, Vinh DC, Kiessling P, Greve B, Jolles S. Targeting FcRn for immunomodulation: Benefits, risks, and practical considerations. J Allergy Clin Immunol 2020; 146:479-491.e5. [PMID: 32896308 PMCID: PMC7471860 DOI: 10.1016/j.jaci.2020.07.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The neonatal fragment crystallizable (Fc) receptor (FcRn) functions as a recycling mechanism to prevent degradation and extend the half-life of IgG and albumin in the circulation. Several FcRn inhibitors selectively targeting IgG recycling are now moving rapidly toward clinical practice in neurology and hematology. These molecules accelerate the destruction of IgG, reducing pathogenic IgG and IgG immune complexes, with no anticipated effects on IgA, IgM, IgE, complement, plasma cells, B cells, or other cells of the innate or adaptive immune systems. FcRn inhibitors have potential for future use in a much wider variety of antibody-mediated autoimmune diseases. Given the imminent clinical use, potential for broader utility, and novel mechanism of action of FcRn inhibitors, here we review data from 4 main sources: (a) currently available activity, safety, and mechanism-of-action data from clinical trials of FcRn inhibitors; (b) other procedures and treatments that also remove IgG (plasma donation, plasma exchange, immunoadsorption); (c) diseases resulting in loss of IgG; and (d) primary immunodeficiencies with potential mechanistic similarities to those induced by FcRn inhibitors. These data have been evaluated to provide practical considerations for the assessment, monitoring, and reduction of any potential infection risk associated with FcRn inhibition, in addition to highlighting areas for future research.
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Affiliation(s)
- Hans-Hartmut Peter
- Freiburg University Hospital, Centre for Chronic Immunodeficiency, Freiburg, Germany
| | - Hans D Ochs
- Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics, University of Washington, Seattle, Wash
| | | | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine and Department of Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada; Infectious Diseases & Immunity in Global Health Program, Research Institute-McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom.
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Pellett Madan R, Penkert RR, Surman SL, Jones BG, Houston J, Lamour JM, Del Rio M, Herold BC, Hurwitz JL. Persistent hypogammaglobulinemia in pediatric solid organ transplant recipients. Clin Transplant 2020; 34:e14021. [PMID: 32575155 DOI: 10.1111/ctr.14021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Hypogammaglobulinemia has not been well studied in pediatric solid organ transplant (SOT) recipients. We evaluated plasma immunoglobulin (Ig) and lymphocyte phenotypes among 31 pediatric heart and kidney recipients for two years post-transplant and from 10 non-transplanted children. METHODS Plasma IgM, IgG, and IgA were quantified by immunoturbidimetric assays, IgG subclasses were quantified by bead-based multiplex immunoassay, and lymphocyte phenotypes were assessed by flow cytometry. RESULTS Median age at transplant for SOT recipients was similar to that of the control cohort (15 vs. 12.5 years, respectively; P = .61). Mean plasma IgG and IgM levels for SOT recipients fell significantly below the control cohort means by 1 month post-transplant (P < .001 for both) and remained lower than control levels at 12-18 months post-transplant. Heart recipients had lower frequencies of a CD4+ naïve T lymphocytes relative to kidney recipients. CONCLUSIONS Hypogammaglobulinemia was prevalent and persistent among pediatric SOT recipients and may be secondary to immunosuppressive medications, as well as loss of thymus tissue and CD45RA+ CD4+ T cells in heart recipients. Limitations of our study include but are not limited to small sample size from a single center, lack of samples for all participants at every time point, and lack of peripheral blood mononuclear cell samples for the non-transplanted cohort.
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Affiliation(s)
- Rebecca Pellett Madan
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Pediatrics, New York University Grossman School of Medicine and Hassenfeld Children's Hospital at NYU Langone, New York, NY, USA
| | - Rhiannon R Penkert
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sherri L Surman
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bart G Jones
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - James Houston
- Department of Neurology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jacqueline M Lamour
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcela Del Rio
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Betsy C Herold
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Julia L Hurwitz
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, TN, USA
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Newman M, Gregg K, Estes R, Pursell K, Pitrak D. Acquired hypogammaglobulinemia and pathogen-specific antibody depletion after solid organ transplantation in human immunodeficiency virus infection: A brief report. Transpl Infect Dis 2019; 21:e13188. [PMID: 31587457 PMCID: PMC6917882 DOI: 10.1111/tid.13188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/15/2019] [Accepted: 09/15/2019] [Indexed: 01/04/2023]
Abstract
Hypogammaglobulinemia (HGG) frequently occurs in recipients after types of (SOT). The incidence and significance of HGG in HIV+ recipients of SOT are just being explored. We reported that 12% of the recipients in the SOT in multi-center HIV-TR (HIV-TR) Study developed moderate or severe HGG at 1 year. In LT recipients, this was associated with serious infections and death. We have now further characterized the decreased antibodies in HIV+ SOT recipients who developed HGG. We measured the levels of pathogen-specific antibodies and poly-specific self-reactive antibodies (PSA) in relation to total IgG levels from serial serum samples for 20 HIV+ SOT recipients who developed moderate to severe HGG following SOT. Serum antibody levels to measles, tetanus toxoid, and HIV-1 were determined by EIA. Levels of PSAs were determined by incubating control lymphocytes with patient serum, staining with anti-human IgG Fab-FITC, and analysis by flow cytometry. Levels of PSA were higher compared to healthy, HIV-uninfected controls at pre-transplant baseline and increased by weeks 12 and 26, but the changes were not significant. Likewise, anti-HIV antibody levels remained unchanged over time. In contrast, antibody levels against measles and tetanus were significantly reduced from baseline by week 12, and did not return to baseline, even after 2 years. For HIV patients who develop moderate to severe HGG after transplant, the reduction in IgG levels is associated with a significant decrease in pathogen-specific antibody titers, while PSA levels and anti-HIV antibodies are unchanged. This may contribute to infectious complications and other clinical endpoints.
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Affiliation(s)
- Margaret Newman
- University of Chicago Medicine, Chicago, IL; Section of Infectious Diseases and Global Health
| | - Kevin Gregg
- University of Michigan, Ann Arbor, MI; Division of Infectious Diseases
| | - Randee Estes
- University of Chicago Medicine, Chicago, IL; Section of Infectious Diseases and Global Health
| | - Kenneth Pursell
- University of Chicago Medicine, Chicago, IL; Section of Infectious Diseases and Global Health
| | - David Pitrak
- University of Chicago Medicine, Chicago, IL; Section of Infectious Diseases and Global Health
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9
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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10
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Lavríková P, Sečník P, Kubíček Z, Jabor A, Hošková L, Franeková J. Tacrolimus has immunosuppressive effects on heavy/light chain pairs and free light chains in patients after heart transplantation: A relationship with infection. Transpl Immunol 2018; 50:43-47. [DOI: 10.1016/j.trim.2018.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 06/07/2018] [Accepted: 06/11/2018] [Indexed: 11/25/2022]
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11
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Murthy SC, Avery RK, Budev M, Gupta S, Pettersson GB, Nowicki ER, Mehta A, Chapman JT, Rajeswaran J, Blackstone EH. Low pretransplant IgA level is associated with early post-lung transplant seromucous infection. J Thorac Cardiovasc Surg 2018; 156:882-891.e8. [PMID: 29779634 DOI: 10.1016/j.jtcvs.2018.03.165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 03/06/2018] [Accepted: 03/10/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Infection is an important cause of morbidity and mortality after lung transplantation. Immunoglobulins are part of both seromucous (IgA) and serum (IgG) infection defense mechanisms. We therefore hypothesized that lower pretransplant IgA levels would be associated with more early post-lung transplant seromucous infections and greater mortality independent of IgG. METHODS From January 2000 to July 2010, 538 patients undergoing primary lung transplantation had pretransplant IgA (n = 429) and IgG (n = 488) measured as a clinical routine. Median IgA was 200 mg·dL-1 (2% < 70 mg·dL-1, lower limit of normal); median IgG was 970 mg·dL-1 (5% < 600 mg·dL-1). Intensive microbiology review was used to categorize infections and their causative organisms within the first posttransplant year. RESULTS In total, 397 seromucous infections were observed in 247 patients, most bacterial. Although IgA and IgG were moderately correlated (r = 0.5, P < .0001), low pretransplant IgA was a strong risk factor (P = .01) for seromucous infections, but pretransplant IgG was not (P ≥ .6). As pretransplant IgA levels fell below 200 mg·dL-1, the risk of these posttransplant infections rose nearly linearly. Lower pretransplant levels of IgA were associated with greater posttransplant mortality to end of follow-up (P = .004), but pretransplant IgG was not (P ≥ .3). CONCLUSIONS Low levels of preoperative IgA, an important immunoglobulin involved in mucosal immunologic defense, but not IgG, are associated with seromucous infections in the year after lung transplantation and increased follow-up mortality. It would appear prudent to identify patients with relative IgA deficiency at listing and to increase vigilance of monitoring for, and prophylaxis against, seromucous infection in this high-risk population.
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Affiliation(s)
- Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Robin K Avery
- Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marie Budev
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sandeep Gupta
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward R Nowicki
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Atul Mehta
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey T Chapman
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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12
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Sarmiento E, Jaramillo M, Calahorra L, Fernandez-Yañez J, Gomez-Sanchez M, Crespo-Leiro MG, Paniagua M, Almenar L, Cebrian M, Rabago G, Levy B, Segovia J, Gomez-Bueno M, Lopez J, Mirabet S, Navarro J, Rodriguez-Molina JJ, Fernandez-Cruz E, Carbone J. Evaluation of humoral immunity profiles to identify heart recipients at risk for development of severe infections: A multicenter prospective study. J Heart Lung Transplant 2016; 36:529-539. [PMID: 27866926 DOI: 10.1016/j.healun.2016.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/17/2016] [Accepted: 10/12/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND New biomarkers are necessary to improve detection of the risk of infection in heart transplantation. We performed a multicenter study to evaluate humoral immunity profiles that could better enable us to identify heart recipients at risk of severe infections. METHODS We prospectively analyzed 170 adult heart recipients at 8 centers in Spain. Study points were before transplantation and 7 and 30 days after transplantation. Immune parameters included IgG, IgM, IgA and complement factors C3 and C4, and titers of specific antibody to pneumococcal polysaccharide antigens (anti-PPS) and to cytomegalovirus (CMV). To evaluate potential immunologic mechanisms leading to IgG hypogammaglobulinemia, before heart transplantation we assessed serum B-cell activating factor (BAFF) levels using enzyme-linked immunoassay. The clinical follow-up period lasted 6 months. Clinical outcome was need for intravenous anti-microbials for therapy of infection. RESULTS During follow-up, 53 patients (31.2%) developed at least 1 severe infection. We confirmed that IgG hypogammaglobulinemia at Day 7 (defined as IgG <600 mg/dl) is a risk factor for infection in general, bacterial infections in particular, and CMV disease. At Day 7 after transplantation, the combination of IgG <600 mg/dl + C3 <80 mg/dl was more strongly associated with the outcome (adjusted odds ratio 7.40; 95% confidence interval 1.48 to 37.03; p = 0.014). We found that quantification of anti-CMV antibody titers and lower anti-PPS antibody concentrations were independent predictors of CMV disease and bacterial infections, respectively. Higher pre-transplant BAFF levels were a risk factor of acute cellular rejection. CONCLUSION Early immunologic monitoring of humoral immunity profiles proved useful for the identification of heart recipients who are at risk of severe infection.
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Affiliation(s)
- Elizabeth Sarmiento
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Maria Jaramillo
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Leticia Calahorra
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Juan Fernandez-Yañez
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Maria G Crespo-Leiro
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Maria Paniagua
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Luis Almenar
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Monica Cebrian
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Gregorio Rabago
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Beltran Levy
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier Segovia
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Manuel Gomez-Bueno
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Lopez
- Heart Failure and Heart Transplant Unit, Hospital Clínico Universitario, Valladolid, Spain
| | - Sonia Mirabet
- Cardiology Department, Sant Pau Hospital, Barcelona, Spain
| | - Joaquin Navarro
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Eduardo Fernandez-Cruz
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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13
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Abstract
Intravenous ganciclovir and, increasingly, oral valganciclovir are now considered the mainstay of treatment for cytomegalovirus (CMV) infection or CMV disease. Under certain circumstances, CMV immunoglobulin (CMVIG) may be an appropriate addition or, indeed, alternative. Data on monotherapy with CMVIG are limited, but encouraging, for example in cases of ganciclovir intolerance. In cases of recurrent CMV in thoracic transplant patients after a disease- and drug-free period, adjunctive CMVIG can be considered in patients with hypogammaglobulinemia. Antiviral-resistant CMV, which is more common among thoracic organ recipients than in other types of transplant, can be an indication for introduction of CMVIG, particularly in view of the toxicity associated with other options, such as foscarnet. Due to a lack of controlled trials, decision-making is based on clinical experience. In the absence of a robust evidence base, it seems reasonable to consider the use of CMVIG to treat CMV in adult or pediatric thoracic transplant patients with ganciclovir-resistant infection, or in serious or complicated cases. The latter can potentially include (i) treatment of severe clinical manifestations, such as pneumonitis or eye complications; (ii) patients with a positive biopsy in end organs, such as the lung or stomach; (iii) symptomatic cases with rising polymerase chain reaction values (for example, higher than 5.0 log10) despite antiviral treatment; (iv) CMV disease or CMV infection or risk factors, such as CMV-IgG–negative serostatus; (vi) ganciclovir intolerance; (vii) patients with hypogammaglobulinemia.
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14
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Carbone J. The Immunology of Posttransplant CMV Infection: Potential Effect of CMV Immunoglobulins on Distinct Components of the Immune Response to CMV. Transplantation 2016; 100 Suppl 3:S11-8. [PMID: 26900990 PMCID: PMC4764014 DOI: 10.1097/tp.0000000000001095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/14/2022]
Abstract
The immune response to cytomegalovirus (CMV) infection is highly complex, including humoral, cellular, innate, and adaptive immune responses. Detection of CMV by the innate immune system triggers production of type I IFNs and inflammatory cytokines which initiate cellular and humoral responses that are critical during the early viremic phase of CMV infection. Sustained control of CMV infection is largely accounted for by cellular immunity, involving various T-cell and B-cell subsets. In solid organ transplant patients, global suppression of innate and adaptive immunities by immunosuppressive agents limits immunological defense, including inhibition of natural killer cell activity with ongoing lowering of Ig levels and CMV-specific antibody titers. This is coupled with a short-term suppression of CMV-specific T cells, the extent and duration of which can predict risk of progression to CMV viremia. CMV immunoglobulin (CMVIG) preparations have the potential to exert immunomodulatory effects as well as providing passive immunization. Specific CMVIG antibodies and virus neutralization might be enhanced by modulation of dendritic cell activity and by a decrease in T-cell activation, effects which are of importance during the initial phase of infection. In summary, the role of CMVIG in reconstituting specific anti-CMV antibodies may be enhanced by some degree of modulation of the innate and adaptive immune responses, which could help to control some of the direct and indirect effects of CMV infection.
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Affiliation(s)
- Javier Carbone
- Clinical Immunology Department, General University Hospital Gregorio Marañon, Complutense University, Madrid, Spain
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15
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Sarmiento E, Navarro J, Fernandez-Yañez J, Palomo J, Muñoz P, Carbone J. Evaluation of an immunological score to assess the risk of severe infection in heart recipients. Transpl Infect Dis 2014; 16:802-12. [PMID: 25179534 DOI: 10.1111/tid.12284] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/14/2014] [Accepted: 06/18/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND We previously reported how specific humoral and cellular immunological markers that are readily available in clinical practice can be used to identify heart transplant recipients (HTR) at risk of developing severe infections. In this study, we perform an extended analysis to identify immunological profiles that could prove to be superior to individual markers in assessing the risk of infection early after heart transplantation. METHODS In a prospective follow-up study, we evaluated 100 HTR at 1 week after transplantation. Laboratory tests included determination of immunoglobulin (Ig) levels (IgG, IgA, IgM), complement factors (C3 and C4), and lymphocyte subsets (CD3+, CD4+, CD8+ T cells, B cells, and natural killer [NK] cells). The prevalence of infection during the first 3 months was registered at scheduled visits after transplantation. Severe infections were defined as all infections requiring hospitalization and intravenous antimicrobial therapy. RESULTS During follow-up, 33 patients (33%) developed severe infections. The individual risk factors of severe infection, according to the Cox regression analysis, were as follows: IgG <600 mg/dL (hazard ratio [HR], 2.41; 95% confidence interval [CI], 1.21-4.78; P = 0.012), C3 <80 mg/dL (HR, 4.65; 95% CI, 2.31-9.38; P < 0.0001), C4 <18 mg/dL (HR 2.30, 95% CI, 1.15-4.59; P = 0.018), NK count <30 cells/μL (HR 4.07, 95% CI, 1.76-9.38; P = 0.001), and CD4 count <350 cells/μL (HR, 3.04; 95% CI, 1.47-6.28; P = 0.0027). An immunological score was created. HRs were used to determine the number of points assigned to each of the 5 previously mentioned individual risk factors. The score was obtained from the sum of these factors. In the multivariate Cox regression analysis, the immunological score was useful for identifying patients at risk of infection and was the only variable that maintained a significant association with the development of infection, after adjustment for the 5 individual factors. CONCLUSION Patients with an immunological score ≥13 were at the highest risk of severe infections (HR, 9.29; 95% CI, 4.57-18.90; P < 0.0001). This score remained significantly associated with the risk of severe infection after adjustment for clinical risk factors of infection. An immunological score was useful for identifying HTR at risk of developing severe infections. If this score is validated in multicenter studies, it could be easily introduced into clinical practice.
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Affiliation(s)
- E Sarmiento
- Clinical Immunology Department, University Hospital Gregorio Marañon, Madrid, Spain
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16
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Clostridium difficile Infection (CDI) in Solid Organ and Hematopoietic Stem Cell Transplant Recipients. Curr Infect Dis Rep 2014; 16:414. [DOI: 10.1007/s11908-014-0414-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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An International Survey of Cytomegalovirus Prevention and Treatment Practices in Intestinal Transplantation. Transplantation 2014; 97:78-82. [DOI: 10.1097/tp.0b013e3182a6baa2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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18
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Avery RK, Blumberg EA. Hypogammaglobulinemia: time to reevaluate? Am J Transplant 2013; 13:2517-8. [PMID: 23924193 DOI: 10.1111/ajt.12403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 06/25/2013] [Accepted: 06/25/2013] [Indexed: 01/25/2023]
Affiliation(s)
- R K Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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19
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Florescu DF, Kalil AC, Qiu F, Schmidt CM, Sandkovsky U. What is the impact of hypogammaglobulinemia on the rate of infections and survival in solid organ transplantation? A meta-analysis. Am J Transplant 2013; 13:2601-10. [PMID: 23919557 DOI: 10.1111/ajt.12401] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/28/2013] [Accepted: 05/31/2013] [Indexed: 01/25/2023]
Abstract
Hypogammaglobulinemia has been described after solid organ transplantation and has been associated with increased risk of infections. The aim of the study was to evaluate the rate of severe hypogammaglobulinemia and its relationship with the risk of infections during the first year posttransplantation. Eighteen studies (1756 patients) that evaluated hypogammaglobulinemia and posttransplant infections were included. The data were pooled using the DerSimonian and Laird random-effects model. Q statistic method was used to assess statistical heterogeneity. Within the first year posttransplantation, the rate of hypogammaglobulinemia (IgG < 700 mg/dL) was 45% (95% CI: 0.34-0.55; Q = 330.1, p < 0.0001), the rate of mild hypogammaglobulinemia (IgG = 400-700 mg/dL) was 39% (95% CI: 0.22-0.56; Q = 210.09, p < 0.0001) and the rate of severe hypogammaglobulinemia (IgG < 400 mg/dL) was 15% (95% CI: 0.08-0.22; Q = 50.15, p < 0.0001). The rate of hypogammaglobulinemia by allograft type: heart 49% (21%-78%; Q = 131.16, p < 0.0001); kidney 40% (30%-49%; Q = 24.55, p = 0.0002); liver 16% (0.001%-35%; Q = 14.31, p = 0.0002) and lung 63% (53%-74%; Q = 6.85, p = 0.08). The odds of respiratory infection (OR = 4.83; 95% CI: 1.66-14.05; p = 0.004; I(2) = 0%), CMV (OR = 2.40; 95% CI: 1.16-4.96; p = 0.02; I(2) = 26.66%), Aspergillus (OR = 8.19; 95% CI: 2.38-28.21; p = 0.0009; I(2) = 17.02%) and other fungal infections (OR = 3.69; 95% CI: 1.11-12.33; p = 0.03; I(2) = 0%) for patients with IgG < 400 mg/dL were higher than the odds for patients with IgG > 400 mg/dL. The odds for 1-year all-cause mortality for severe hypogammaglobulinemia group was 21.91 times higher than those for IgG > 400 mg/dL group (95% CI: 2.49-192.55; p = 0.005; I(2) = 0%). Severe hypogammaglobulinemia during the first year posttransplantation significantly increased the risk of CMV, fungal and respiratory infections, and was associated with higher 1-year all-cause mortality.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE; Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE
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20
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Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Danziger-Isakov L, Humar A. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333-60. [PMID: 23896556 DOI: 10.1097/tp.0b013e31829df29d] [Citation(s) in RCA: 558] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) continues to be one of the most common infections after solid-organ transplantation, resulting in significant morbidity, graft loss, and adverse outcomes. Management of CMV varies considerably among transplant centers but has been become more standardized by publication of consensus guidelines by the Infectious Diseases Section of The Transplantation Society. An international panel of experts was reconvened in October 2012 to revise and expand evidence and expert opinion-based consensus guidelines on CMV management, including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues. The following report summarizes the recommendations.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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21
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Shankar T, Gribowicz J, Crespo M, Silveira F, Pilewski J, Petrov A. Subcutaneous IgG replacement therapy is safe and well tolerated in lung transplant recipients. Int Immunopharmacol 2013; 15:752-5. [DOI: 10.1016/j.intimp.2013.02.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 02/11/2013] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
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22
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Sarmiento E, del Pozo N, Gallego A, Fernández-Yañez J, Palomo J, Villa A, Ruiz M, Muñoz P, Rodríguez C, Rodríguez-Molina J, Navarro J, Kotsch K, Fernandez-Cruz E, Carbone J. Decreased levels of serum complement C3 and natural killer cells add to the predictive value of total immunoglobulin G for severe infection in heart transplant recipients. Transpl Infect Dis 2012; 14:526-39. [DOI: 10.1111/j.1399-3062.2012.00757.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E. Sarmiento
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - N. del Pozo
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - A. Gallego
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - J. Fernández-Yañez
- Cardiology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - J. Palomo
- Cardiology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - A. Villa
- Cardiology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - M. Ruiz
- Cardiovascular Surgery Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - P. Muñoz
- Microbiology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - C. Rodríguez
- Biochemistry Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - J. Rodríguez-Molina
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - J. Navarro
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - K. Kotsch
- Transplant Immunology Group; Immunology Institute; Universitätsmedizin Charité; Berlin; Germany
| | - E. Fernandez-Cruz
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
| | - J. Carbone
- Clinical Immunology Department; University Hospital Gregorio Marañón; Madrid; Spain
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23
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Carbone J, Sarmiento E, Del Pozo N, Rodriguez-Molina J, Navarro J, Fernandez-Yañez J, Palomo J, Villa A, Muñoz P, Fernandez-Cruz E. Restoration of humoral immunity after intravenous immunoglobulin replacement therapy in heart recipients with post-transplant antibody deficiency and severe infections. Clin Transplant 2012; 26:E277-83. [DOI: 10.1111/j.1399-0012.2012.01653.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J. Carbone
- Clinical Immunology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - E. Sarmiento
- Clinical Immunology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - N. Del Pozo
- Clinical Immunology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | | | - J. Navarro
- Clinical Immunology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - J. Fernandez-Yañez
- Cardiology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - J. Palomo
- Cardiology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - A. Villa
- Cardiology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - P. Muñoz
- Microbiology Department; University Hospital Gregorio Marañon; Madrid; Spain
| | - E. Fernandez-Cruz
- Clinical Immunology Department; University Hospital Gregorio Marañon; Madrid; Spain
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24
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Muñoz P, Crespo Leiro MG. [Prophylaxis of cytomegalovirus infection in heart transplantation]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:52-5. [PMID: 22541924 DOI: 10.1016/s0213-005x(11)70059-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cytomegalovirus (CMV) is a common complication after heart transplantation, affecting almost half of all recipients. The clinical spectrum of this infection includes, in order of greater to lesser severity, latent infection, asymptomatic viremia, CMV syndrome and CMV disease. CMV is associated with rejection and vascular graft disease and is a major cause of morbidity and mortality. The factors most frequently involved in susceptibility to this infection and its severity are donor and recipient CMV serological status, the intensity of immunosuppression and the type of immunosuppressive agents used. The management strategies of this infection include universal or targeted prophylaxis, preemptive therapy and treatment of established disease. The use of preventive measures significantly reduces the incidence of symtomatic infection or CMV disease, which has been reported to be less than 3% in some recent series.
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Affiliation(s)
- Patricia Muñoz
- Servicio de Microbiología-Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, CIBERES, GESITRA, REIPI, España.
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25
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Carbone J, del Pozo N, Gallego A, Sarmiento E. Immunological risk factors for infection after immunosuppressive and biologic therapies. Expert Rev Anti Infect Ther 2011; 9:405-13. [PMID: 21504398 DOI: 10.1586/eri.10.178] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Immunosuppressive and biologic therapies are costly and can involve a considerable risk of infection. Noninvasive diagnostic tools for early prediction of infection before and after administration of these therapies are of major interest. Serial longitudinal immune monitoring would provide data on immunocompetence and complement clinical follow-up protocols. Biomarkers of immune response may be useful to identify patients at risk of developing infection and who could be candidates for immunosuppressant dose reduction. This article focuses on the potential use of biomarkers of immune response to predict development of infection after immunosuppressive and biologic therapies in selected settings of autoimmune disease (rituximab for treatment of rheumatoid arthritis) and solid organ transplantation.
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Affiliation(s)
- Javier Carbone
- Transplant Immunology Group, Clinical Immunology Department, University Hospital Gregorio Marañon, Doctor Esquerdo 46, 28007 Madrid, Spain.
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26
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Muñoz P, Giannella M, Michaels MG, Bouza E. Heart, lung and heart–lung transplantation. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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27
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Sarmiento E, Lanio N, Gallego A, Rodriguez-Molina J, Navarro J, Fernandez-Yañez J, Palomo J, Rodríguez-Hernández C, Ruiz M, Alonso R, Fernandez-Cruz E, Carbone J. Immune monitoring of anti cytomegalovirus antibodies and risk of cytomegalovirus disease in heart transplantation. Int Immunopharmacol 2008; 9:649-52. [PMID: 18940269 DOI: 10.1016/j.intimp.2008.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 09/25/2008] [Indexed: 10/21/2022]
Abstract
We sought to determine whether quantitative assessment of anti-cytomegalovirus (CMV) antibodies could be useful to identify patients at risk of cytomegalovirus (CMV) disease after heart transplantation (HT). 75 patients who underwent HT at a single health care center were prospectively studied. Induction therapy included 2 doses of daclizumab and maintenance tacrolimus (n=42) or cyclosporine (n=29), mycophenolate mofetil and prednisone. All patients received prophylaxis with gancyclovir or valganciclovir. Anti-CMV intravenous immunoglobulin (CMV-IG) was added in high risk patients (CMV D+/R- serostatus). Serial determinations of anti-CMV antibodies, immunoglobulins (IgG, IgA, IgM) and IgG-subclasses were analysed. CMV infection was based on detection of the virus by antigenemia. CMV disease consisted of detection of signs or symptoms attributable to this microorganism. Ten patients (13.3%) developed CMV disease. Mean time of development of CMV disease was 3.4+/-1.6 months. In Cox regression analysis, patients with low baseline anti-CMV titers (<4.26 natural logarithm of titer, RH: 8.1, 95%CI: 1.93-34.1, p=0.004) and recipients with 1-month post-HT IgG hypogammaglobulinemia (IgG<500 mg/dl, RH: 4.49, 95%CI: 1.26-15.94, p=0.02) were at higher risk of having CMV disease. Despite use of prophylactic CMV-IG, D+/R- patients showed significantly lower titers of anti-CMV antibodies at 7 d, 30 d and 90 d post HT as compared with HT recipients without infections. Four out of 6 of these patients developed late CMV disease. Monitoring of specific anti-CMV antibodies on the bedside warrants further evaluation as a potential tool to identify heart transplant recipients at higher risk of CMV disease.
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Affiliation(s)
- Elizabeth Sarmiento
- Transplant Immunology Group, Immunology Department, University Hospital Gregorio Marañon, Madrid, Spain.
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Furst DE. Serum immunoglobulins and risk of infection: how low can you go? Semin Arthritis Rheum 2008; 39:18-29. [PMID: 18620738 DOI: 10.1016/j.semarthrit.2008.05.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 05/02/2008] [Accepted: 05/04/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the relationship between the levels of serum immunoglobulin (Ig) levels and risk of infection. The following 2 main questions are addressed: (1) At what level do reduced serum concentrations of the different Ig species (focusing on IgA, IgG, and IgM) significantly increase the risk of infection above background and (2) For how long can Ig depletion be tolerated before an increased risk of infection becomes apparent. METHODS Information was gathered from a search of PubMed and relevant congress abstracts up to and including November 2007. RESULTS Sustained, very low levels of IgA, IgG, or IgM, as occur in primary immunodeficiency syndromes, are associated with significantly increased risks of infections, primarily respiratory tract infections of bacterial origin. Patients with IgG levels <100 mg/dL or IgM levels <20 mg/dL for prolonged periods have an increased risk of recurrent and sometimes life-threatening infectious episodes. Generally, IgA deficiency appears better tolerated. Replenishment of IgG in patients with hypogammaglobulinemia reduces the infection risk to background if IgG levels are maintained at approximately 500 mg/dL, although higher levels may be necessary in the presence of certain comorbidities. Transient depletion of IgG and/or IgM (or, less commonly, IgA) can occur in some patients following the administration of certain drugs, including anticonvulsants, corticosteroids, and rituximab. Available evidence suggests that such changes are not generally associated with an increased risk of infections. CONCLUSIONS While prolonged, very low levels of IgG and/or IgM are associated with a heightened risk of infections, transient or less severe immunodeficiency appears to be tolerated in most subjects.
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Affiliation(s)
- Daniel E Furst
- University of California, Los Angeles, CA 90095-1670, USA.
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Bouza E, Loeches B, Muñoz P. Fever of Unknown Origin in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2007; 21:1033-54, ix-x. [DOI: 10.1016/j.idc.2007.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sarmiento E, Rodríguez-Hernández C, Rodríguez-Molina J, Fernández-Yánez J, Palomo J, Anguita J, Pérez JL, Lanio N, Fernández-Cruz E, Carbone J. Impaired anti-pneumococcal polysaccharide antibody production and invasive pneumococcal infection following heart transplantation. Int Immunopharmacol 2006; 6:2027-30. [PMID: 17161358 DOI: 10.1016/j.intimp.2006.09.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 09/15/2006] [Indexed: 11/20/2022]
Abstract
An increased risk of invasive pneumococcal infection has been described among adult heart transplant (HT) recipients. Vaccination has been recommended before HT but the appropriate time for revaccination is not known. In a preliminary analysis of a prospective study involving a cohort of 32 HT recipients receiving daclizumab and triple immunosuppresion therapy, a progressive decline in pneumococcal polysaccharide antibody (anti-PPS) levels was observed during the first year after HT. One of the patients who was found to have a decrease in the levels of anti-PPS developed severe pneumococcal meningitis 20 months after HT. Before HT he had received non-conjugated 23-valent pneumococcal vaccine and showed a normal post-immunization anti-PPS production. The data suggest that long-term immunologic monitoring might be useful to recognize impairment of antibody responses under immunosuppressive therapy in HT.
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Affiliation(s)
- E Sarmiento
- Immunology Department, University General Hospital Gregorio Marañon, Madrid, Spain
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