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Schmidt C, Weißmüller S, Heinz CC. Multifaceted Tissue-Protective Functions of Polyvalent Immunoglobulin Preparations in Severe Infections-Interactions with Neutrophils, Complement, and Coagulation Pathways. Biomedicines 2023; 11:3022. [PMID: 38002022 PMCID: PMC10669904 DOI: 10.3390/biomedicines11113022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Severe infections induce immune defense mechanisms and initial tissue damage, which produce an inflammatory neutrophil response. Upon dysregulation of these responses, inflammation, further tissue damage, and systemic spread of the pathogen may occur. Subsequent vascular inflammation and activation of coagulation processes may cause microvascular obstruction at sites distal to the primary site of infection. Low immunoglobulin (Ig) M and IgG levels have been detected in patients with severe infections like sCAP and sepsis, associated with increased severity and mortality. Based on Ig's modes of action, supplementation with polyvalent intravenous Ig preparations (standard IVIg or IgM/IgA-enriched Ig preparations) has long been discussed as a treatment option for severe infections. A prerequisite seems to be the timely administration of Ig preparations before excessive tissue damage has occurred and coagulopathy has developed. This review focuses on nonclinical and clinical studies that evaluated tissue-protective activities resulting from interactions of Igs with neutrophils, complement, and the coagulation system. The data indicate that coagulopathy, organ failure, and even death of patients can possibly be prevented by the timely combined interactions of (natural) IgM, IgA, and IgG with neutrophils and complement.
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Affiliation(s)
- Carolin Schmidt
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
| | | | - Corina C Heinz
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
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2
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Heise EL, Chichelnitskiy E, Greer M, Franz M, Aburahma K, Iablonskii P, de Manna ND, Christoph S, Verboom M, Hallensleben M, Boethig D, Avsar M, Welte T, Schwerk N, Sommer W, Haverich A, Warnecke G, Kuehn C, Falk C, Salman J, Ius F. Lung transplantation despite preformed donor-specific antihuman leukocyte antigen antibodies: a 9-year single-center experience. Am J Transplant 2023; 23:1740-1756. [PMID: 37225088 DOI: 10.1016/j.ajt.2023.04.034] [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: 12/26/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/26/2023]
Abstract
Pretransplant allosensitization to human leukocyte antigens (HLA) increases the recipient's waiting list time and mortality in lung transplantation. Rather than waiting for crossmatch-negative donors, since 2013, recipients with preformed donor-specific antiHLA antibodies (pfDSA) have been managed with repeated IgA- and IgM-enriched intravenous immunoglobulin (IgGAM) infusions, usually in combination with plasmapheresis before IgGAM and a single dose of antiCD20 antibody. This retrospective study presents our 9-year experience with patients transplanted with pfDSA. Records of patients transplanted between February 2013 and May 2022 were reviewed. Outcomes were compared between patients with pfDSA and those without any de novo donor-specific antiHLA antibodies. The median follow-up time was 50 months. Of the 1,043 patients who had undergone lung transplantation, 758 (72.7%) did not develop any early donor-specific antiHLA antibodies, and 62 (5.9%) patients exhibited pfDSA. Among the 52 (84%) patients who completed treatment, pfDSA was cleared in 38 (73%). In pfDSA vs control patients and at 8-year follow-up, respectively, graft survival (%) was 75 vs 65 (P = .493) and freedom from chronic lung allograft dysfunction (%) was 63 vs 65 (P = .525). In lung transplantation, crossing the preformed HLA-antibody barrier is safe using a treatment protocol based on IgGAM. Patients with pfDSA have a good 8-year graft survival rate and freedom from chronic lung allograft dysfunction, similar to control patients.
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Affiliation(s)
- Emma L Heise
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Evgeny Chichelnitskiy
- Department of Transplantation Immunology, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine,Hannover Medical School,Hannover,Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Maximilian Franz
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Khalil Aburahma
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Pavel Iablonskii
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany; Medical Faculty, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Nunzio D de Manna
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Stella Christoph
- Department of Transplantation Immunology, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael Hallensleben
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine,Hannover Medical School,Hannover,Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Nicolaus Schwerk
- Department of Pediatric Pneumology Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Christine Falk
- Department of Transplantation Immunology, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Hannover/Heidelberg, Germany.
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Bohländer F. A new hope? Possibilities of therapeutic IgA antibodies in the treatment of inflammatory lung diseases. Front Immunol 2023; 14:1127339. [PMID: 37051237 PMCID: PMC10083398 DOI: 10.3389/fimmu.2023.1127339] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Inflammatory lung diseases represent a persistent burden for patients and the global healthcare system. The combination of high morbidity, (partially) high mortality and limited innovations in the last decades, have resulted in a great demand for new therapeutics. Are therapeutic IgA antibodies possibly a new hope in the treatment of inflammatory lung diseases? Current research increasingly unravels the elementary functions of IgA as protector against infections and as modulator of overwhelming inflammation. With a focus on IgA, this review describes the pathological alterations in mucosal immunity and how they contribute to chronic inflammation in the most common inflammatory lung diseases. The current knowledge of IgA functions in the circulation, and particularly in the respiratory mucosa, are summarized. The interplay between neutrophils and IgA seems to be key in control of inflammation. In addition, the hurdles and benefits of therapeutic IgA antibodies, as well as the currently known clinically used IgA preparations are described. The data highlighted here, together with upcoming research strategies aiming at circumventing the current pitfalls in IgA research may pave the way for this promising antibody class in the application of inflammatory lung diseases.
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Schmidt C, Weißmüller S, Bohländer F, Germer M, König M, Staus A, Wartenberg-Demand A, Heinz CC, Schüttrumpf J. The Dual Role of a Polyvalent IgM/IgA-Enriched Immunoglobulin Preparation in Activating and Inhibiting the Complement System. Biomedicines 2021; 9:817. [PMID: 34356880 PMCID: PMC8301464 DOI: 10.3390/biomedicines9070817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Activation of the complement system is important for efficient clearance of a wide variety of pathogens via opsonophagocytosis, or by direct lysis via complement-dependent cytotoxicity (CDC). However, in severe infections dysregulation of the complement system contributes to hyperinflammation. The influence of the novel IgM/IgA-enriched immunoglobulin preparation trimodulin on the complement pathway was investigated in in vitro opsonophagocytosis, binding and CDC assays. Immunoglobulin levels before and after trimodulin treatment were placed in relation to complement assessments in humans. In vitro, trimodulin activates complement and induces opsonophagocytosis, but also interacts with opsonins C3b, C4b and anaphylatoxin C5a in a concentration-dependent manner. This was not observed for standard intravenous IgG preparation (IVIg). Accordingly, trimodulin, but not IVIg, inhibited the downstream CDC pathway and target cell lysis. If applied at a similar concentration range in healthy subjects, trimodulin treatment resulted in C3 and C4 consumption in a concentration-dependent manner, which was extended in patients with severe community-acquired pneumonia. Complement consumption is found to be dependent on underlying immunoglobulin levels, particularly IgM, pinpointing their regulative function in humans. IgM/IgA provide a balancing effect on the complement system. Trimodulin may enhance phagocytosis and opsonophagocytosis in patients with severe infections and prevent excessive pathogen lysis and release of harmful anaphylatoxins.
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Affiliation(s)
- Carolin Schmidt
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Sabrina Weißmüller
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Fabian Bohländer
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Matthias Germer
- Preclinical Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Martin König
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Alexander Staus
- Corporate Biostatistics, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Andrea Wartenberg-Demand
- Corporate Clinical Research & Development, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Corina C. Heinz
- Clinical Strategy & Development, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Jörg Schüttrumpf
- Corporate R&D, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
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Jarczak D, Kluge S, Nierhaus A. Sepsis-Pathophysiology and Therapeutic Concepts. Front Med (Lausanne) 2021; 8:628302. [PMID: 34055825 PMCID: PMC8160230 DOI: 10.3389/fmed.2021.628302] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.
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Affiliation(s)
- Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Immohr MB, Akhyari P, Aubin H, Westenfeld R, Mehdiani A, Bruno RR, Sipahi NF, Erbel-Khurtsidze S, Reinecke P, Tudorache I, Lichtenberg A, Boeken U. Treatment of donor-specific antibody-mediated rejection after heart transplantation by IgM-enriched human immunoglobulin. ESC Heart Fail 2021; 8:3413-3417. [PMID: 33969938 PMCID: PMC8318410 DOI: 10.1002/ehf2.13409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/07/2021] [Accepted: 04/24/2021] [Indexed: 12/25/2022] Open
Abstract
Antibody‐mediated graft rejection caused by donor‐specific antibodies (DSA‐MR) remains a serious problem after heart transplantation (HTx). IgM‐enriched human intravenous immunoglobulin (IGM‐IVIG) consists of 76% IgG, 12% IgM, and 12% IgA and provides a new multifactorial approach for DSA‐MR. Between 2017 and 2020, four (P1–4) of 102 patients developed DSA‐MR after HTx in our department and were repetitively treated with IGM‐IVIG in combination with anti‐thymocyte globulin. While in P1 and P4, DSA‐MR occurred within the early post‐operative interval, P2 and P3 developed DSA‐MR approximately 1 year after transplantation. An impairment of ventricular function was observed in three of four patients. Furthermore, P1 and P4 suffered from malign ventricular arrhythmias. After the application of IGM‐IVIG, the ventricular function recovered, and all patients could be discharged from the hospital. As part of a multifactorial therapeutic approach, treatment with IGM‐IVIG seems to be a safe and effective strategy to address DSA‐MR.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Arash Mehdiani
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Nihat Firat Sipahi
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Sophiko Erbel-Khurtsidze
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Petra Reinecke
- Institute of Pathology, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
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Berlot G, Scamperle A, Istrati T, Dattola R, Longo I, Chillemi A, Baronio S, Quarantotto G, Zanchi S, Roman-Pognuz E, Bixio M, Tomasini A. Kinetics of Immunoglobulins in Septic Shock Patients Treated With an IgM- and IgA-Enriched Intravenous Preparation: An Observational Study. Front Med (Lausanne) 2021; 8:605113. [PMID: 33732713 PMCID: PMC7956982 DOI: 10.3389/fmed.2021.605113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: To assess the variations of the blood levels of immunoglobulins (Ig) in septic shock patients treated with an Ig preparation enriched in IgM and IgA (eIg). Design: The blood levels of Ig in survivors (S) and non-survivors (NS) of a group of septic shock patients were measured before the initial administration (D0) and 1 (D1), 4 (D4), and 7 (D7) days thereafter. The SAPS II score, the capillary permeability, the primary site of infection, the antibiotic appropriateness, and the outcome at 28 days were also assessed. Results: In the interval D0–D7, the IgM increased significantly only in the S while remained stable in NS; the IgA significantly increased in both groups; the IgG did not vary significantly in both groups. At D4, the capillary permeability significantly decreased in S but not in NS. Conclusions: The kinetics of the different classes of Ig after eIg were different between S and NS. This could be related either to (a) different capillary permeability in the two groups or to (b) higher Ig consumption in NS. Further studies to confirm the benefits of eIg in the treatment of sepsis syndrome and to define the specific target population and the correct eIg dose are warranted.
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Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Alice Scamperle
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Tatiana Istrati
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Roberto Dattola
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Irene Longo
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Antonino Chillemi
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Silvia Baronio
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Giada Quarantotto
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Silvia Zanchi
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Mattia Bixio
- Department of Anesthesia and Intensive Care, San Martino Hospital, Genova, Italy
| | - Ariella Tomasini
- Department of Anesthesia and Intensive Care, Cattinara Hospital, University of Trieste, Trieste, Italy
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Nierhaus A, Berlot G, Kindgen-Milles D, Müller E, Girardis M. Best-practice IgM- and IgA-enriched immunoglobulin use in patients with sepsis. Ann Intensive Care 2020; 10:132. [PMID: 33026597 PMCID: PMC7538847 DOI: 10.1186/s13613-020-00740-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/06/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Despite treatment being in line with current guidelines, mortality remains high in those with septic shock. Intravenous immunoglobulins represent a promising therapy to modulate both the pro- and anti-inflammatory processes and can contribute to the elimination of pathogens. In this context, there is evidence of the benefits of immunoglobulin M (IgM)- and immunoglobulin A (IgA)-enriched immunoglobulin therapy for sepsis. This manuscript aims to summarize current relevant data to provide expert opinions on best practice for the use of an IgM- and IgA-enriched immunoglobulin (Pentaglobin) in adult patients with sepsis. Main text Sepsis patients with hyperinflammation and patients with immunosuppression may benefit most from treatment with IgM- and IgA-enriched immunoglobulin (Pentaglobin). Patients with hyperinflammation present with phenotypes that manifest throughout the body, whilst the clinical characteristics of immunosuppression are less clear. Potential biomarkers for hyperinflammation include elevated procalcitonin, interleukin-6, endotoxin activity and C-reactive protein, although thresholds for these are not well-defined. Convenient biomarkers for identifying patients in a stage of immune-paralysis are still matter of debate, though human leukocyte antigen–antigen D related expression on monocytes, lymphocyte count and viral reactivation have been proposed. The timing of treatment is potentially more critical for treatment efficacy in patients with hyperinflammation compared with patients who are in an immunosuppressed stage. Due to the lack of evidence, definitive dosage recommendations for either population cannot be made, though we suggest that patients with hyperinflammation should receive an initial bolus at a rate of up to 0.6 mL (30 mg)/kg/h for 6 h followed by a continuous maintenance rate of 0.2 mL (10 mg)/kg/hour for ≥ 72 h (total dose ≥ 0.9 g/kg). For immunosuppressed patients, dosage is more conservative (0.2 mL [10 mg]/kg/h) for ≥ 72 h, without an initial bolus (total dose ≥ 0.72 g/kg). Conclusions Two distinct populations that may benefit most from Pentaglobin therapy are described in this review. However, further clinical evidence is required to strengthen support for the recommendations given here regarding timing, duration and dosage of treatment.
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Affiliation(s)
- Axel Nierhaus
- University Medical Center Hamburg, Hamburg, Germany. .,Dep. of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Jarczak D, Kluge S, Nierhaus A. Use of Intravenous Immunoglobulins in Sepsis Therapy-A Clinical View. Int J Mol Sci 2020; 21:ijms21155543. [PMID: 32756325 PMCID: PMC7432410 DOI: 10.3390/ijms21155543] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction, defined by a dysregulated host immune response to infection. During sepsis, the finely tuned system of immunity, inflammation and anti-inflammation is disturbed in a variety of ways. Both pro-inflammatory and anti-inflammatory pathways are upregulated, activation of the coagulation cascade and complement and sepsis-induced lymphopenia occur. Due to the manifold interactions in this network, the use of IgM-enriched intravenous immunoglobulins seems to be a promising therapeutic approach. Unfortunately, there is still a lack of evidence-based data to answer the important questions of appropriate patient populations, optimal timing and dosage of intravenous immunoglobulins. With this review, we aim to provide an overview of the role of immunoglobulins, with emphasis on IgM-enriched formulations, in the therapy of adult patients with sepsis and septic shock.
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10
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Ius F, Müller C, Sommer W, Verboom M, Hallensleben M, Salman J, Siemeni T, Kühn C, Avsar M, Bobylev D, Poyanmehr R, Erdfelder C, Böthig D, Carlens J, Bayir L, Hansen G, Blasczyk R, Falk C, Tecklenburg A, Haverich A, Tudorache I, Schwerk N, Warnecke G. Six-year experience with treatment of early donor-specific anti-HLA antibodies in pediatric lung transplantation using a human immunoglobulin-based protocol. Pediatr Pulmonol 2020; 55:754-764. [PMID: 31909902 DOI: 10.1002/ppul.24639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/27/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Experience with the treatment of early donor-specific anti-HLA antibodies (eDSA) after lung transplantation in children is very limited. At our institution, we have treated patients with eDSA since 2013 with successive infusions of intravenous human immunoglobulins (IVIG), combined in some cases with a single dose of Rituximab and plasmapheresis (therapeutic plasma exchange [tPE]) or immunoabsorption. The aim of this study was to present the 6-year results of IVIG-based therapy in pediatric lung recipients. METHODS Records of pediatric (<18 years old) patients transplanted at our institution between 01/2013 and 03/2019 were reviewed. Outcomes were compared between patients with eDSA treated with IVIG (IVIG group) and without eDSA (control group). Median (interquartile range [IQR]) follow-up amounted to 28 (12-52) months. RESULTS During the study period, 66 lung-transplanted pediatric patients were included, of which 27 (41%) formed the IVIG group and 38 (57%) the control group. Among the IVIG patients, 14 (52%) patients showed concomitant graft dysfunction (possible clinical antibody-mediated rejection). The median time to eDSA detection was 24 (14-63) days after transplantation. eDSA were cleared in 25 (96%) of the 26 patients which completed treatment. At 3 years, graft survival (%) was 73 vs 85 (P = .65); freedom (%) from chronic lung allograft rejection (CLAD) was 89 vs 78 (P = .82); and from infection 47 vs 31 (P = .15), in IVIG vs control patients, respectively. CONCLUSIONS After lung transplantation, an IVIG-based treatment for eDSA yielded high eDSA clearance. IVIG and control patients showed similar CLAD-free and graft survival.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Murielle Verboom
- Institute of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | | | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Böthig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Carlens
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Lale Bayir
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Christine Falk
- German Center for Lung Research (DZL/BREATH), Hannover, Germany.,Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
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11
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Immunotherapy for recurrent pregnancy loss. Best Pract Res Clin Obstet Gynaecol 2019; 60:77-86. [DOI: 10.1016/j.bpobgyn.2019.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/21/2022]
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12
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Abstract
For myocarditis and inflammatory cardiomyopathy, an etiologically driven treatment is today the best option beyond heart failure therapy. Prerequisites for this are noninvasive and invasive biomarkers including endomyocardial biopsy and polymerase chain reaction on cardiotropic agents. Imaging by Doppler echocardiography and cardiac magnetic resonance imaging as well as cardiac biomarkers such as C‑reactive protein, N‑terminal pro-B-type natriuretic peptide , and troponins can contribute to the clinical work-up of the syndrome but not toward elucidating the underlying cause or pathogenetic process. This review summarizes the phases and clinical features of myocarditis and gives an up-to-date short overview of the current treatment options starting with heart failure and antiarrhythmic therapy. Although inflammation in myocardial disease can resolve spontaneously, often specific treatment directed against the causative agent is required. For fulminant, acute, and chronic autoreactive myocarditis, immunosuppressive treatment has proven to be beneficial in the TIMIC and ESETCID trials; for viral cardiomyopathy and myocarditis, intravenous immunoglobulin IgG subtype and polyvalent intravenous immunoglobulins IgG, IgA, and IgM can frequently resolve inflammation. However, despite the elimination of inflammation, the eradication of parvovirus B19 and human herpesvirus-6 is still a challenge, for which ivIg treatment can become a future key player.
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Affiliation(s)
- B Maisch
- Fachbereich Medizin, Philipps-Universität Marburg und Herz- und Gefäßzentrum (HGZ) Marburg, Feldbergstr. 45, 35043, Marburg, Germany.
| | - P Alter
- Klinik für Innere Medizin-Pneumologie und Intensivmedizin, UKGM und Philipps-Universität Marburg, Marburg, Germany
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13
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Maisch B. Cardio-Immunology of Myocarditis: Focus on Immune Mechanisms and Treatment Options. Front Cardiovasc Med 2019; 6:48. [PMID: 31032264 PMCID: PMC6473396 DOI: 10.3389/fcvm.2019.00048] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/27/2019] [Indexed: 12/13/2022] Open
Abstract
Myocarditis and inflammatory cardiomyopathy are syndromes, not aetiological disease entities. From animal models of cardiac inflammation we have detailed insight of the strain specific immune reactions based on the genetic background of the animal and the infectiosity of the virus. Innate and adaptive immunity also react in man. An aetiological diagnosis of a viral vs. a non-viral cause is possible by endomyocardial biopsy with histology, immunohistology and PCR for microbial agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy on the basis of the genetic background and the predisposition for inflammation. It analyses the epidemiologic shift in cardiotropic viral agents in the last 30 years. Based on the understanding of the interaction between infection and the players of the innate and adaptive immune system it summarizes pathogenetic phases and clinical faces of myocarditis. It gives an up-to-date information on specific treatment options beyond symptomatic heart failure and antiarrhythmic therapy. Although inflammation can resolve spontaneously, specific treatment directed to the causative etiology is often required. For fulminant, acute, and chronic autoreactive myocarditis without viral persistence immunosuppressive treatment can be life-saving, for viral inflammatory cardiomyopathy ivIg treatment can resolve inflammation and often eradicate the virus.
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Affiliation(s)
- Bernhard Maisch
- Faculty of Medicine, and Heart and Vessel Center, Philipps-University, Marburg, Germany
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14
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Fereidan-Esfahani M, Nayfeh T, Warrington A, Howe CL, Rodriguez M. IgM Natural Autoantibodies in Physiology and the Treatment of Disease. Methods Mol Biol 2019; 1904:53-81. [PMID: 30539466 DOI: 10.1007/978-1-4939-8958-4_3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibodies are vital components of the adaptive immune system for the recognition and response to foreign antigens. However, some antibodies recognize self-antigens in healthy individuals. These autoreactive antibodies may modulate innate immune functions. IgM natural autoantibodies (IgM-NAAs) are a class of primarily polyreactive immunoglobulins encoded by germline V-gene segments which exhibit low affinity but broad specificity to both foreign and self-antigens. Historically, these autoantibodies were closely associated with autoimmune disease. Nevertheless, not all human autoantibodies are pathogenic and compelling evidence indicates that IgM-NAAs may exert a spectrum of effects from injurious to protective depending upon cellular and molecular context. In this chapter, we review the current state of knowledge regarding the potential physiological and therapeutic roles of IgM-NAAs in different disease conditions such as atherosclerosis, cancer, and autoimmune disease. We also describe the discovery of two reparative IgM-NAAs by our laboratory and delineate their proposed mechanisms of action in central nervous system (CNS) disease.
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Affiliation(s)
| | - Tarek Nayfeh
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Charles L Howe
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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15
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Berlot G, Vassallo MC, Busetto N, Nieto Yabar M, Istrati T, Baronio S, Quarantotto G, Bixio M, Barbati G, Dattola R, Longo I, Chillemi A, Scamperle A, Iscra F, Tomasini A. Effects of the timing of administration of IgM- and IgA-enriched intravenous polyclonal immunoglobulins on the outcome of septic shock patients. Ann Intensive Care 2018; 8:122. [PMID: 30535962 PMCID: PMC6288102 DOI: 10.1186/s13613-018-0466-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/30/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The administration of endovenous immunoglobulins in patients with septic shock could be beneficial and preparations enriched with IgA and IgM (ivIgGAM) seem to be more effective than those containing only IgG. In a previous study Berlot et al. demonstrated that early administration of ivIgGAM was associated with lower mortality rate. We studied a larger population of similar patients aiming either to confirm or not this finding considering also the subgroup of patients with septic shock by multidrug-resistant (MDR) pathogens. METHODS Adult patients with septic shock in intensive care unit (ICU) treated with ivIgGAM from August 1999 to December 2016 were retrospectively examined. Collected data included the demographic characteristics of the patients, the diagnosis at admission, SOFA, SAPS II and Murray Lung Injury Score (LIS), characteristics of the primary infection, the adequacy of antimicrobial therapy, the delay of administration of ivIgGAM from the ICU admission and the outcome at the ICU discharge. Parametric and nonparametric tests and logistic regression were used for statistic analysis. RESULTS During the study period 107 (30%) of the 355 patients died in ICU. Survivors received the ivIgGAM earlier than nonsurvivors (median delay 12 vs 14 h), had significantly lower SAPS II, SOFA and LIS at admission and a lower rate of MDR- and fungal-related septic shock. The appropriateness of the administration of antibiotics was similar in survivors and nonsurvivors (84 vs 79%, respectively, p: n.s). The delay in the administration of ivIgGAM from the admission was associated with in-ICU mortality (odds ratio per 1-h increase = 1.0055, 95% CI 1.003-1.009, p < 0.001), independently of SAPS II, LIS, cultures positive for MDR pathogens or fungi and onset of septic shock. Only 46 patients (14%) had septic shock due to MDR pathogens; 21 of them (46%) died in ICU. Survivors had significantly lower SAPS II, SOFA at admission and delay in administration of ivIgGAM than nonsurvivors (median delay 18 vs 66 h). Even in this subgroup the delay in the administration of ivIgGAM from the admission was associated with an increased risk of in-ICU mortality (odds ratio 1.007, 95% CI 1.0006-1.014, p = 0.048), independently of SAPS II. CONCLUSIONS Earlier administration of ivIgGAM was associated with decreased risk of in-ICU mortality both in patients with septic shock caused by any pathogens and in patients with MDR-related septic shock.
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Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Michele Claudio Vassallo
- Department of Anesthesia and Intensive Care, San Martino Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Nicola Busetto
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Margarita Nieto Yabar
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Tatiana Istrati
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Silvia Baronio
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Giada Quarantotto
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Mattia Bixio
- Department of Anesthesia and Intensive Care, San Martino Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Giulia Barbati
- Biostatistics Unit, Department of Medicine, Surgery and Health Sciences, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Roberto Dattola
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Irene Longo
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Antonino Chillemi
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Alice Scamperle
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Fulvio Iscra
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Ariella Tomasini
- Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
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16
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Ius F, Verboom M, Sommer W, Poyanmehr R, Knoefel A, Salman J, Kuehn C, Avsar M, Siemeni T, Erdfelder C, Hallensleben M, Boethig D, Schwerk N, Mueller C, Welte T, Falk C, Haverich A, Tudorache I, Warnecke G. Preemptive treatment of early donor-specific antibodies with IgA- and IgM-enriched intravenous human immunoglobulins in lung transplantation. Am J Transplant 2018; 18:2295-2304. [PMID: 29719115 PMCID: PMC6585979 DOI: 10.1111/ajt.14912] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/11/2018] [Accepted: 04/19/2018] [Indexed: 01/25/2023]
Abstract
This retrospective study presents our 4-year experience of preemptive treatment of early anti-HLA donor specific antibodies with IgA- and IgM-enriched immunoglobulins. We compared outcomes between patients with antibodies and treatment (case patients) and patients without antibodies (control patients). Records of patients transplanted at our institution between March 2013 and November 2017 were reviewed. The treatment protocol included one single 2 g/kg immunoglobulin infusion followed by successive 0.5 g/kg infusions for a maximum of 6 months, usually combined with a single dose of anti-CD20 antibody and, in case of clinical rejection or positive crossmatch, with plasmapheresis or immunoabsorption. Among the 598 transplanted patients, 128 (21%) patients formed the case group and 452 (76%) the control group. In 116 (91%) patients who completed treatment, 106 (91%) showed no antibodies at treatment end. Fourteen (13%) patients showed antibody recurrence thereafter. In case versus control patients and at 4-year follow-up, respectively, graft survival (%) was 79 versus 81 (P = .59), freedom (%) from biopsy-confirmed rejection 57 versus 53 (P = .34), and from chronic lung allograft dysfunction 82 versus 78 (P = .83). After lung transplantation, patients with early donor-specific antibodies and treated with IgA- and IgM-enriched immunoglobulins had 4-year graft survival similar to patients without antibodies and showed high antibody clearance.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Murielle Verboom
- Department of TransfusionMedicine Hannover Medical SchoolHannoverGermany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Ann‐Kathrin Knoefel
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | | | - Dietmar Boethig
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Nicolaus Schwerk
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Department of PaediatricsHannover Medical SchoolHannoverGermany
| | - Carsten Mueller
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Department of PaediatricsHannover Medical SchoolHannoverGermany
| | - Tobias Welte
- German Center for Lung Research (DZL/BREATH)HannoverGermany,Department of Respiratory MedicineHannover Medical SchoolHannoverGermany
| | - Christine Falk
- Institute of Transplant ImmunologyHannover Medical SchoolHannoverGermany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
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17
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Geier C, Schröder J, Tamm A, Dietz S, Nuding S, Holder K, Khandanpour Ö, Werdan K, Ebelt H. Influence of the serum levels of immunoglobulins on clinical outcomes in medical intensive-care patients. Med Klin Intensivmed Notfmed 2015; 112:30-37. [PMID: 26681382 DOI: 10.1007/s00063-015-0121-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/30/2015] [Accepted: 09/30/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Endogenous immunoglobulins (Igs) are of fundamental importance in the host defense after microbial infections. However, the therapeutic administration of intravenous IgG (IVIgG) has not yet been shown to improve clinical outcomes in patients suffering from sepsis, and in the case of IgM-containing preparations (IVIgGMA) the positive evidence is only weak. Recently published studies implicate that Ig levels on admission could have an impact on the patient's response to IVIg treatment and on outcomes of critically ill patients. METHODS In this noninterventional study, the serum levels of IgG, IgM, and IgA were determined in 340 medical patients on ICU admission, and clinical outcomes were prospectively recorded (ICU mortality, need for renal replacement therapy (RRT), need for mechanical ventilation, substitution of coagulation factors, and amount of red cell transfusions). Patients were prospectively grouped according to their main reason for ICU admission (sepsis, respiratory failure, cardiovascular diseases, acute renal failure, postoperative condition, state after cardiopulmonal resuscitation, gastrointestinal diseases, and others). RESULTS AND DISCUSSION There was no correlation between the Ig levels on admission and ICU mortality neither in the total cohort of medical ICU patients nor in any prespecified subgroup. However, in a logistic regression model that was adjusted for APACHE II score on admission, an increase in serum IgG was associated with a reduced need for mechanical ventilation in patients suffering from cardiovascular disease. On the other hand, in patients suffering from sepsis, an increased level of IgM was linked to an increased administration of coagulation factors. CONCLUSION Our data do not support the hypothesis that serum levels of immunoglobulins are linked to mortality in medical ICU patients.
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Affiliation(s)
- C Geier
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - J Schröder
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - A Tamm
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - S Dietz
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - S Nuding
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - K Holder
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Ö Khandanpour
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - K Werdan
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - H Ebelt
- Department of Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany.
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18
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Abstract
Immunoglobulins (Ig) or antibodies are heavy plasma proteins, with sugar chains added to amino-acid residues by N-linked glycosylation and occasionally by O-linked glycosylation. The versatility of antibodies is demonstrated by the various functions that they mediate such as neutralization, agglutination, fixation with activation of complement and activation of effector cells. Naturally occurring antibodies protect the organism against harmful pathogens, viruses and infections. In addition, almost any organic chemical induces antibody production of antibodies that would bind specifically to the chemical. These antibodies are often produced from multiple B cell clones and referred to as polyclonal antibodies. In recent years, scientists have exploited the highly evolved machinery of the immune system to produce structurally and functionally complex molecules such as antibodies from a single B clone, heralding the era of monoclonal antibodies. Most of the antibodies currently in the clinic, target components of the immune system, are not curative and seek to alleviate symptoms rather than cure disease. Our group used a novel strategy to identify reparative human monoclonal antibodies distinct from conventional antibodies. In this chapter, we discuss the therapeutic relevance of both polyclonal and monoclonal antibodies in clinic.
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Affiliation(s)
- Bharath Wootla
- Departments of Neurology and Immunology, Mayo Clinic, Rochester, MN, USA
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19
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Abstract
In inflammatory dilated cardiomyopathy and myocarditis there is--apart from heart failure and antiarrhythmic therapies--no alternative to an aetiologically driven specific treatment. Prerequisite are noninvasive and invasive biomarkers including endomyocardial biopsy and PCR on cardiotropic agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy including the genetic background, the predisposition for heart failure and inflammation. It analyses the epidemiologic shift in pathogenetic agents in the last 20 years, the role of innate and aquired immunity including the T- and B-cell driven immune responses. The phases and clinical faces of myocarditis are summarized. Up-to-date information on current treatment options starting with heart failure and antiarrhythmic therapy are provided. Although inflammation can resolve spontaneously, specific treatment directed to the causative aetiology is often required. For fulminant, acute and chronic autoreactive myocarditis immunosuppressive treatment is beneficial, while for viral cardiomyopathy and myocarditis ivIg can resolve inflammation and is as successful as interferon therapy in enteroviral and adenoviral myocarditis. For Parvo B19 and HHV6 myocarditis eradication of the virus is still a problem by any of these treatment options. Finally, the potential of stem cell therapy has to be tested in future trials. In virus-negative, autoreactive perimyocardial disease a locoregional approach with intrapericardial instillation of high local doses of triamcinolone acetate has been shown to be highly efficient and with few systemic side-effects.
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20
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Standard and etiology-directed evidence-based therapies in myocarditis: state of the art and future perspectives. Heart Fail Rev 2012; 18:761-95. [DOI: 10.1007/s10741-012-9362-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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21
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Kaveri SV, Silverman GJ, Bayry J. Natural IgM in immune equilibrium and harnessing their therapeutic potential. THE JOURNAL OF IMMUNOLOGY 2012; 188:939-45. [PMID: 22262757 DOI: 10.4049/jimmunol.1102107] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Natural IgM Abs are the constitutively secreted products of B1 cells (CD5(+) in mice and CD20(+)CD27(+)CD43(+)CD70(-) in humans) that have important and diverse roles in health and disease. Whereas the role of natural IgM as the first line of defense for protection against invading microbes has been extensively investigated, more recent reports have highlighted their potential roles in the maintenance of tissue homeostasis via clearance of apoptotic and altered cells through complement-dependent mechanisms, inhibition of inflammation, removal of misfolded proteins, and regulation of pathogenic autoreactive IgG Abs and autoantibody-producing B cells. These observations have provided the theoretical underpinnings for efforts that currently seek to harness the untapped therapeutic potential of natural IgM either by boosting in vivo natural IgM production or via therapeutic infusions of monoclonal and polyclonal IgM preparations.
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22
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Stehr SN, Knels L, Weissflog C, Schober J, Haufe D, Lupp A, Koch T, Heller AR. Effects of IGM-enriched solution on polymorphonuclear neutrophil function, bacterial clearance, and lung histology in endotoxemia. Shock 2008; 29:167-72. [PMID: 17666945 DOI: 10.1097/shk.0b013e318067df15] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immunological interventions in endotoxemia and sepsis have been tested in experimental and clinical studies. Our group evaluated the effects of an immunoglobulin (Ig)M-enriched solution in an established model of Gram-negative bacteraemia. Ten New Zealand White rabbits (2-3 kg) were randomized to a treatment or control group. In both groups, LPS was infused at a rate of 40 mg kg(-1) h(-1). Immunoglobulin M-enriched solution (Pentaglobin; 2 mL kg(-1) h(-1)) was applied in the intervention group 15 min after beginning LPS infusion. 1 x 10(8) colony forming units of Escherichia coli were injected 30 min after LPS infusion was commenced. Baseline hemodynamic and respiratory parameters, blood E. coli concentration (30 min before and 1, 15, 30, 60, 90, 120, and 180 min after E. coli injection), polymorphonuclear neutrophil oxidative burst activity, and phagocytosis dead space (both 30 min before and 1, 15, 60, 120, and 180 min postinjection) were measured. Ex vivo phagocytosis activity was measured in a separate experiment and evaluated by electron microscopy. Diffuse alveolar damage (DAD) was measured. Organ colonization (kidney, lung, liver, spleen) was assessed in aseptic organ samples. Hemodynamic parameters did not differ between the two groups. Bacterial blood clearance was not influenced by application of IgM-enriched solution. Liver and spleen colonization was significantly reduced in the IgM group. Immunoglobulin M-enriched solution reduced in vitro residual phagocytosis capacity at 30, 90, and 180 min and improved respiratory burst at 180 min. Correspondingly, ex vivo phagocytosis activity as documented by electron microscopy was increased in the IgM group. The sum of all weighted DAD scores (except overdistension) was significantly better in the IgM group (23+/-5 vs. 30+/-8). Immunoglobulin M-enriched solution significantly improved six of seven DAD score parameters and reduced liver and spleen E. coli count. Residual phagocytosis capacity was significantly decreased in the IgM group, whereas burst activity was increased, pointing to an increased in vivo phagocytosis efficiency. Short-term IgM-enriched solution intervention had an especially beneficial effect on LPS-induced pulmonary histological changes.
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Affiliation(s)
- Sebastian N Stehr
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
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23
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Immunoglobulin M-enriched human intravenous immunoglobulins reduce leukocyte-endothelial cell interactions and attenuate microvascular perfusion failure in normotensive endotoxemia. Shock 2008; 29:133-9. [PMID: 18246604 DOI: 10.1097/shk.0b013e318123e5a6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical studies indicate potential differences in the efficacy of immunoglobulin (Ig) preparations in patients with sepsis. A recent meta-analysis showed improved survival rates with IgM-enriched Igs. It was the objective of the present study to characterize microcirculatory actions of different clinically used Ig preparations in a rodent endotoxin model by intravital microscopy. Male Syrian golden hamsters 6 to 8 weeks old with a body weight of 60 to 80 g were investigated by intravital fluorescence microscopy. Endotoxemia was induced by administration of 2 mg/kg (i.v.) endotoxin (LPS, Escherichia coli). Two different Ig preparations containing IgM, IgA, and IgG (intravenous IgM group; n = 6; 5 mL Pentaglobin/kg body weight, i.v.) or exclusively IgG (intravenous IgG group; n = 5; 5 mL Flebogamma/kg body weight, i.v.) were applied 5 min before LPS. Saline-treated endotoxemic animals served as controls (control; n = 8). In controls, LPS induced massive leukocyte-endothelial cell interactions, pronounced microvascular leakage, a decrease of systemic platelet count, and distinct capillary perfusion failure (P < 0.05). Both intravenous IgM and IgG reduced venular leakage (P< 0.05) and ameliorated the decrease in platelet count (P < 0.05). Of interest, intravenous IgM was capable of significantly (P< 0.05) reducing leukocyte adhesion in venules. This was associated with normalization of capillary perfusion at 24 h of endotoxemia, whereas intravenous IgG could not prevent LPS-mediated microvascular perfusion failure. We demonstrate that IgM-enriched Igs are superior to IgG alone in attenuating LPS-induced leukocytic inflammation and microcirculatory dysfunction. Our findings can explain better efficacy of IgM-enriched Igs in patients with severe sepsis.
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24
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Casadevall A, Pirofski LA. A Reappraisal of Humoral Immunity Based on Mechanisms of Antibody‐Mediated Protection Against Intracellular Pathogens. Adv Immunol 2006; 91:1-44. [PMID: 16938537 DOI: 10.1016/s0065-2776(06)91001-3] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sometime in the mid to late twentieth century the study of antibody-mediated immunity (AMI) entered the doldrums, as many immunologists believed that the function of AMI was well understood, and was no longer deserving of intensive investigation. However, beginning in the 1990s studies using monoclonal antibodies (mAbs) revealed new functions for antibodies, including direct antimicrobial effects and their ability to modify host inflammatory and cellular responses. Furthermore, the demonstration that mAbs to several intracellular bacterial and fungal pathogens were protective issued a serious challenge to the paradigm that host defense against such microbes was strictly governed by cell-mediated immunity (CMI). Hence, a new view of AMI is emerging. This view is based on the concept that a major function of antibody (Ab) is to amplify or subdue the inflammatory response to a microbe. In this regard, the "damage-response framework" of microbial pathogenesis provides a new conceptual viewpoint for understanding mechanisms of AMI. According to this view, the ability of an Ab to affect the outcome of a host-microbe interaction is a function of its capacity to modify the damage ensuing from such an interaction. In fact, it is increasingly apparent that the efficacy of an Ab cannot be defined either by immunoglobulin or epitope characteristics alone, but rather by a complex function of Ab variables, such as specificity, isotype, and amount, host variables, such as genetic background and immune status, and microbial variables, such as inoculum, mechanisms of avoiding host immune surveillance and pathogenic strategy. Consequently, far from being understood, recent findings in AMI imply a system with unfathomable complexity and the field is poised for a long overdue renaissance.
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Affiliation(s)
- Arturo Casadevall
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefoire Medical Center, Bronx, New York, USA
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Affiliation(s)
- Arturo Casadevall
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Ave., Bronx, NY 10461, USA.
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Buhler LH. Xenotransplantation literature update March-April, 2004. Xenotransplantation 2004; 11:383-6. [PMID: 15196137 DOI: 10.1111/j.1399-3089.2004.00150.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Leo H Buhler
- Associate Editor, Xenotransplantation, Department of Surgery, University Hospital Geneva, Geneva, Switzerland.
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