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Sharma A, Triplett BM, Chi L, Cross SJ, Zheng Y, Arnold PY. Donor-derived anti-HLA antibodies in a haploidentical hematopoietic cell transplant recipient shortly after transplant. Hum Immunol 2024; 85:110829. [PMID: 38824859 DOI: 10.1016/j.humimm.2024.110829] [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: 04/28/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
A pediatric patient with acute myeloid leukemia was referred to our institution for investigational therapy after disease relapse following a mismatched unrelated donor hematopoietic cell transplant (HCT). Prior to second HCT, the patient's serum was negative for antibodies to class I and class II HLA. Eight days after receiving a maternal donor haploidentical transplant, the patient became platelet refractory and highly sensitized to multiple class I HLA. Serum from the patient's mother was positive for the strongest antibodies present in the patient, suggesting the antibodies were donor-derived. Patient sera showed magnified and expanded sensitization over time in the context of 100% donor chimerism and despite undetectable circulating B cells. Escalating sensitization suggests active transfer of rituximab-resistant antibody-producing passenger lymphocytes from a haploidentical donor to a transplant recipient at the time of progenitor cell infusion. Evaluation of donor sensitization status may be a consideration prior to HLA mismatched HCT.
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Affiliation(s)
- Akshay Sharma
- Departments of Bone Marrow Transplant and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon M Triplett
- Departments of Bone Marrow Transplant and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Liying Chi
- Departments of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Shane J Cross
- Departments of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yan Zheng
- Departments of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paula Y Arnold
- Departments of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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2
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Tung JP, Chiaretti S, Dean MM, Sultana AJ, Reade MC, Fung YL. Transfusion-related acute lung injury (TRALI): Potential pathways of development, strategies for prevention and treatment, and future research directions. Blood Rev 2022; 53:100926. [DOI: 10.1016/j.blre.2021.100926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/01/2021] [Accepted: 12/30/2021] [Indexed: 02/08/2023]
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3
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Tran VL, Parsons S, Nuibe A. The Trilogy of SARS-CoV-2 in Pediatrics (Part 2): Multisystem Inflammatory Syndrome in Children. J Pediatr Pharmacol Ther 2021; 26:318-338. [PMID: 34035676 DOI: 10.5863/1551-6776-26.4.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
Multisystem Inflammatory Syndrome in Children (MIS-C) was first recognized as a novel illness in 2020 with manifestations similar to other hyperinflammatory syndromes, such as Kawasaki disease or macrophage activation syndrome. Severity varies from a self-limited febrile illness to shock requiring inotropes and mechanical ventilation. Gastrointestinal symptoms and persistent fevers are the most common clinical symptoms, with the addition of cardiac manifestations inclusive of ventricular dysfunction and coronary artery aneurysms. With no controlled trials or comparative effectiveness studies evaluating treatment of MIS-C to date, current treatment with immunomodulatory agents has mainly been derived from previous experience treating Kawasaki disease. This article provides a comprehensive review summarizing published data for the evaluation and management of MIS-C, with a focus on pharmacotherapy treatment considerations.
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4
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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Noulsri E. Effects of Cell-Derived Microparticles on Immune Cells and Potential Implications in Clinical Medicine. Lab Med 2020; 52:122-135. [PMID: 32816040 DOI: 10.1093/labmed/lmaa043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In the past few years, interest has increased in cell-derived microparticles (MPs), which are defined by their size of from 0.1 to 1 μm, and can be derived from various cell types, including endothelial cells, leukocytes, red blood cells (RBCs), and platelets. These MPs carry negatively charged phosphatidylserine (PS) on their surfaces and proteins packaged from numerous cellular components. MPs that have been shed by the body can play important roles in the pathophysiology of diseases and can affect various biological systems. Among these systems, the immune components have been shown to be modulated by MPs. Therefore, understanding the roles of MPs in the immune system is crucial to developing alternative therapeutic treatments for diseases. This review describes the effects of MPs on various immune cells and provides plausible potential applications of the immune-modulating properties of MPs in clinical medicine.
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Affiliation(s)
- Egarit Noulsri
- Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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6
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Acute Respiratory Distress Syndrome in Cancer Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123590 DOI: 10.1007/978-3-319-74588-6_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous form of acute, diffuse lung injury that is characterized by dysregulated inflammation, increased alveolar-capillary interface permeability, and non-cardiogenic pulmonary edema. In the general population, the incidence and mortality associated with ARDS over the last two decades have steadily declined in parallel with optimized approaches to pneumonia and other underlying causes of ARDS as well as increased utilization of multimodal treatment strategies that include lung-protective ventilation. In the cancer settings, significant declines in the incidence and mortality of ARDS over the past two decades have also been reported, although these rates remain significantly higher than those in the general population. Epidemiologic studies identify infection, including disseminated fungal pneumonias, as a major underlying cause of ARDS in the cancer setting. More than half of cancer patients who develop ARDS will not survive to hospital discharge. Those who do survive often face a protracted and often incomplete recovery, resulting in significant long-term physical, psychological, and cognitive sequelae. The residual organ dysfunction and poor functional status after ARDS may delay or preclude subsequent cancer treatments. As such, close collaboration between the critical care physicians and oncology team is essential in identifying and reversing the underlying causes and optimizing treatments for cancer patients with ARDS. This chapter reviews the diagnosis and common causes of ARDS in cancer and gives an update on the general management principles for cancer patients with ARDS in the ICU.
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Balayla J, Gil Y, Mattina J, Al-Shehri E, Ziegler C. Streptococcal Toxic Shock Syndrome After Insertion of a Levonorgestrel Intrauterine Device. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1772-1774. [DOI: 10.1016/j.jogc.2019.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/08/2019] [Accepted: 02/08/2019] [Indexed: 11/24/2022]
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8
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Baudel JL, Vigneron C, Pras-Landre V, Joffre J, Marjot F, Ait-Oufella H, Bigé N, Maury E, Guidet B, Fain O, Mekinian A. Transfusion-related acute lung injury (TRALI) after intravenous immunoglobulins: French multicentre study and literature review. Clin Rheumatol 2019; 39:541-546. [PMID: 31760541 DOI: 10.1007/s10067-019-04832-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/24/2019] [Accepted: 10/31/2019] [Indexed: 11/29/2022]
Abstract
Transfusion-related acute lung injury (TRALI), defined as the onset of acute respiratory distress after blood transfusion, is a rare complication which is a leading cause of transfusion related-mortality. In this retrospective study, we report the French nationwide experience of intravenous immunoglobulin (IVIG)-related TRALI, with a literature review and analysis of management and outcome of this rare condition. With the pharmacovigilance services, we conducted a retrospective multicenter study in the French network of intensive care units with TRALI concomitant to IVIG use and pooled with data from a literature review. Overall, 17 cases have been included in this case-series, our case report, seven personal cases and nine cases from the literature review. The median age was 55 years [2-79] with 10/17 (59%) male subjects. The underlying diseases motivating IVIG infusion were neurologic diseases in 35% of cases (Guillain Barre syndrome = 2, peripheral neuropathy = 2, neurolupus = 1, myasthenia = 1), multiple myeloma with hypogammaglobulinemia (n = 2; 12%), primary hypogammaglobulinemia (n = 2; 12%), autoimmune cytopenias (n = 2; 12%), graft versus host cutaneous disease after allogeneic hematopoietic stem cell transplantation for acute myeloid leukaemia (n = 1), anti-HLA antibodies after lung transplant (n = 1), cancer-associated thrombotic thrombocytopenic purpura-haemolytic uremic syndrome (n = 1), Kawasaki disease (n = 1) and in experimental essay (n = 1). TRALI symptoms begin either after the start or during the infusion (n = 7; 41%), or after the infusion (n = 10; 59%, 10 min to 24 h). Besides respiratory distress, it was also noted shock (33%), fever (18 %), cough (18%), nausea/vomiting (18 %), chills (12%) and agitation (12%). The X-ray showed mainly bilateral alveolar opacities (n = 15; 88%). Mechanical ventilation was needed in nine cases (53%), with median 1-day duration [1-4]. Four patients (24%) died during hospitalisation in the intensive care unit. Given the increasing use of intravenous immunoglobulins, TRALI must now be discussed in cases of respiratory distress occurring during or immediately following the infusion even if this side effect remains rare.Key Points• TRALI must now be discussed in cases of respiratory distress occurring during or immediately following an infusion of intravenous immunoglobulins.
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Affiliation(s)
- Jean Luc Baudel
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Clara Vigneron
- Sorbonne Université, Service de médecine interne, DHU i2B AP-HP, Hôpital Saint Antoine, 75012, Paris, France
| | - Veronique Pras-Landre
- Sorbonne Université, Service de pharmacovigilance, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Jérémie Joffre
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Frédéric Marjot
- Service de médecine intensive et réanimation, CH Saint Brieuc, Saint-Brieuc, France
| | - Hafid Ait-Oufella
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Naike Bigé
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Eric Maury
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Bertrand Guidet
- Sorbonne Université, Service de médecine intensive et réanimation, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Olivier Fain
- Sorbonne Université, Service de médecine interne, DHU i2B AP-HP, Hôpital Saint Antoine, 75012, Paris, France
| | - Arsène Mekinian
- Sorbonne Université, Service de médecine interne, DHU i2B AP-HP, Hôpital Saint Antoine, 75012, Paris, France. .,Hôpital Saint-Antoine, AP-HP, Service de Medecine Interne, Université Paris 6, 75012, Paris, France.
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Ray S, Gupta RK, Jain D. Transfusion-Related Acute Lung Injury due to Iatrogenic IVIG Overdose in Guillain-Barre Syndrome. J Pediatr Neurosci 2019; 14:140-142. [PMID: 31649774 PMCID: PMC6798284 DOI: 10.4103/jpn.jpn_47_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/23/2019] [Accepted: 06/30/2019] [Indexed: 01/28/2023] Open
Abstract
Transfusion-related acute lung injury (TRALI) is a transfusion-related adverse effect associated with high mortality, manifesting with acute respiratory distress and with features of non-cardiogenic pulmonary edema. It is rarely reported following intravenous immunoglobulin (IVIG) infusion and is even rarer in pediatric population. We here present a 12-year-old female child who presented as a case of acute flaccid paralysis and was diagnosed clinically as Guillain-Barre syndrome. As per protocol, she was given IVIG for 4 of the 5 days therapy at the dose of 0.4mg/kg/day before the patient went to another hospital. Subsequently in the next 1 week, she received two more courses of IVIG in two different hospitals following which she developed respiratory distress and was again admitted in our hospital. A diagnosis of TRALI was leveled on clinical ground because of IVIG overdose. Patient subsequently improved on high-flow oxygen therapy and conservative management. This unfortunate case of iatrogenic IVIG overdose just reinforces the fact of proper documentation of treatment to avoid such mishap and also prompt diagnosis and management of this least recognized entity of TRALI.
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Affiliation(s)
- Sanghamitra Ray
- Department of Paediatrics, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi, India
| | - Rakesh Kumar Gupta
- Department of Paediatrics, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi, India
| | - Deepti Jain
- Department of Paediatrics, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi, India
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10
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Targeting Transfusion-Related Acute Lung Injury: The Journey From Basic Science to Novel Therapies. Crit Care Med 2019; 46:e452-e458. [PMID: 29384784 DOI: 10.1097/ccm.0000000000002989] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Transfusion-related acute lung injury is characterized by the onset of respiratory distress and acute lung injury following blood transfusion, but its pathogenesis remains poorly understood. Generally, a two-hit model is presumed to underlie transfusion-related acute lung injury with the first hit being risk factors present in the transfused patient (such as inflammation), whereas the second hit is conveyed by factors in the transfused donor blood (such as antileukocyte antibodies). At least 80% of transfusion-related acute lung injury cases are related to the presence of donor antibodies such as antihuman leukocyte or antihuman neutrophil antibodies. The remaining cases may be related to nonantibody-mediated factors such as biolipids or components related to storage and ageing of the transfused blood cells. At present, transfusion-related acute lung injury is the leading cause of transfusion-related fatalities and no specific therapy is clinically available. In this article, we critically appraise and discuss recent preclinical (bench) insights related to transfusion-related acute lung injury pathogenesis and their therapeutic potential for future use at the patients' bedside in order to combat this devastating and possibly fatal complication of transfusion. DATA SOURCES We searched the PubMed database (until August 22, 2017). STUDY SELECTION Using terms: "Transfusion-related acute lung injury," "TRALI," "TRALI and therapy," "TRALI pathogenesis." DATA EXTRACTION English-written articles focusing on transfusion-related acute lung injury pathogenesis, with potential therapeutic implications, were extracted. DATA SYNTHESIS We have identified potential therapeutic approaches based on the literature. CONCLUSIONS We propose that the most promising therapeutic strategies to explore are interleukin-10 therapy, down-modulating C-reactive protein levels, targeting reactive oxygen species, or blocking the interleukin-8 receptors; all focused on the transfused recipient. In the long-run, it may perhaps also be advantageous to explore other strategies aimed at the transfused recipient or aimed toward the blood product, but these will require more validation and confirmation first.
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11
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El Helou G, Razonable RR. Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation. Expert Opin Drug Saf 2019; 18:1017-1030. [PMID: 31478398 DOI: 10.1080/14740338.2019.1662787] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.
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Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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12
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Abbas A, Rajabally YA. Complications of Immunoglobulin Therapy and Implications for Treatment of Inflammatory Neuropathy: A Review. Curr Drug Saf 2019; 14:3-13. [PMID: 30332974 DOI: 10.2174/1574886313666181017121139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intravenous Immunoglobulin (IVIg) forms a cornerstone of effective treatment for acute and chronic inflammatory neuropathies, with a class I evidence base in Guillain-Barré Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). It is generally considered to be a safe therapy however there are several recognised complications which are reviewed in this article. DISCUSSION AND CONCLUSION Most adverse events are immediate and mild such as headache, fever and nausea although more serious immediate reactions such as anaphylaxis may rarely occur. Delayed complications are rare but may be serious, including thromboembolic events and acute kidney injury, and these and associated risk factors are also discussed. We emphasise the importance of safe IVIg administration and highlight practical measures to minimise complications of this therapy.
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Affiliation(s)
- Ahmed Abbas
- Department of Neurophysiology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom
| | - Yusuf A Rajabally
- Department of Neurophysiology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom.,Department of Neurology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom.,Department of Aston Brain Centre, Aston University, Birmingham, United Kingdom
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13
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Mangiola M, Marrari M, Ensor C, Spycher MO, Berger M, Zeevi A. Therapeutic Human IgG Preparations Contain Mixture of HLA Antibodies to Native HLA Antigens and Cryptic Epitopes With Little Clinical Significance. Transplantation 2019; 102:2126-2132. [PMID: 29877923 DOI: 10.1097/tp.0000000000002312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Human immunoglobulins (H-Ig) are widely used in solid organ transplantation for immunoglobulin G (IgG) replacement and for desensitization and treatment of antibody-mediated rejection. They are obtained from plasma pools and may contain HLA antibodies that can be detrimental to transplant recipients. The goal of this study was to evaluate HLA antibodies in multiple lots of 2 commercial H-Ig preparations by Luminex single-antigen bead (SAB) and cell-based crossmatch assays. METHODS Thirty lots of 2 commercial H-Ig products (CSL Behring, King of Prussia, PA) were evaluated: 6 Hizentra and 24 Privigen. All were adsorbed and diluted 1:10 before testing. HLA IgG antibodies were determined by 2 Luminex SAB kits and C1q screen for complement-binding capability. Lots were tested for the presence of antibody to denatured vs. intact class I HLA alleles using acid-treated SAB. Surrogate T and B-cell flow cytometry crossmatches (FCXM) were performed with peripheral blood lymphocytes from 2 healthy donors. RESULTS Twenty-two (73%) lots at 1:10 showed SAB reactivity with mean fluorescent intensity of 2000 or greater for HLA class I, 67% (20/30 lots) for class II. The reactivity pattern was similar using both SAB kits. Acid treatment revealed antibodies to denatured class I: the majority of HLA-C, half of HLA-B and few HLA-A alleles. No C1q reactivity was observed. Surrogate flow cytometry crossmatch results were positive (>150 median channel shift), but were fourfold to eightfold lower than expected. CONCLUSIONS The H-Ig products tested consisted of low titer, non-complement-binding HLA class I and class II antibodies; most of the observed class I HLA reactivity was toward denatured HLA antigens.
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Affiliation(s)
- Massimo Mangiola
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Marilyn Marrari
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher Ensor
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | | | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
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15
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Rajan GR. Severe Transfusion-related Acute Lung Injury in the Intensive Care Unit Secondary to Transfusion of Fresh Frozen Plasma. Anaesth Intensive Care 2019; 33:400-2. [PMID: 15973926 DOI: 10.1177/0310057x0503300318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transfusion-related acute lung injury (TRALI) is a life-threatening complication of transfusion of blood products. A case of severe TRALI secondary to infusion of fresh frozen plasma in the intensive care unit is discussed. Additionally, the aetiology and pathogenesis of this relatively under-diagnosed and under-reported clinical entity is reviewed. It is our conclusion that proper diagnosis and reporting is necessary for prompt and appropriate treatment of the patient and to prevent additional reactions in other patients.
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Affiliation(s)
- G R Rajan
- Veteran's Affairs Medical Centre, St Louis, Missouri, USA
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16
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Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:585-594. [PMID: 30570487 PMCID: PMC6324877 DOI: 10.1182/asheducation-2018.1.585] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related morbidity and mortality. These adverse events are characterized by acute pulmonary edema within 6 hours of a blood transfusion and have historically been difficult to study due to underrecognition and nonspecific diagnostic criteria. However, in the past decade, in vivo models and clinical studies utilizing active surveillance have advanced our understanding of their epidemiology and pathogenesis. With the adoption of mitigation strategies and patient blood management, the incidence of TRALI and TACO has decreased. Continued research to prevent and treat these severe cardiopulmonary events is focused on both the blood component and the transfusion recipient.
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Affiliation(s)
- Nareg Roubinian
- Blood Systems Research Institute, San Francisco, CA; Kaiser Permanente Northern California Medical Center and Division of Research, Oakland, CA; and Department of Laboratory Medicine, University of California, San Francisco, CA
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17
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Guo Y, Tian X, Wang X, Xiao Z. Adverse Effects of Immunoglobulin Therapy. Front Immunol 2018; 9:1299. [PMID: 29951056 PMCID: PMC6008653 DOI: 10.3389/fimmu.2018.01299] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/24/2018] [Indexed: 01/09/2023] Open
Abstract
Immunoglobulin has been widely used in a variety of diseases, including primary and secondary immunodeficiency diseases, neuromuscular diseases, and Kawasaki disease. Although a large number of clinical trials have demonstrated that immunoglobulin is effective and well tolerated, various adverse effects have been reported. The majority of these events, such as flushing, headache, malaise, fever, chills, fatigue and lethargy, are transient and mild. However, some rare side effects, including renal impairment, thrombosis, arrhythmia, aseptic meningitis, hemolytic anemia, and transfusion-related acute lung injury (TRALI), are serious. These adverse effects are associated with specific immunoglobulin preparations and individual differences. Performing an early assessment of risk factors, infusing at a slow rate, premedicating, and switching from intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG) can minimize these adverse effects. Adverse effects are rarely disabling or fatal, treatment mainly involves supportive measures, and the majority of affected patients have a good prognosis.
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Affiliation(s)
- Yi Guo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Ueda M, Berger M, Gale RP, Lazarus HM. Immunoglobulin therapy in hematologic neoplasms and after hematopoietic cell transplantation. Blood Rev 2018; 32:106-115. [DOI: 10.1016/j.blre.2017.09.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/28/2017] [Accepted: 09/15/2017] [Indexed: 12/27/2022]
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Ibrahim J, Al Amri A, Ghatasheh G. Transfusion-Related Acute Lung Injury After Immunoglobulin Infusion for Kawasaki Disease: A Case Report and Literature Review. Glob Pediatr Health 2017; 4:2333794X17746545. [PMID: 29308425 PMCID: PMC5751901 DOI: 10.1177/2333794x17746545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 11/08/2017] [Indexed: 11/26/2022] Open
Affiliation(s)
- Judy Ibrahim
- Tawam Hospital, Al Ain City, United Arab Emirates
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20
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Otrock ZK, Liu C, Grossman BJ. Transfusion-related acute lung injury risk mitigation: an update. Vox Sang 2017; 112:694-703. [PMID: 28948604 DOI: 10.1111/vox.12573] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 07/11/2017] [Accepted: 08/11/2017] [Indexed: 02/04/2023]
Abstract
Transfusion-related acute lung injury (TRALI) is a life-threatening complication of transfusion. Greater understanding of the pathophysiology of this syndrome has much improved during the last two decades. Plasma-containing components from female donors with leucocyte antibodies were responsible for the majority of TRALI fatalities before mitigation strategies were implemented. Over the past 15 years, measures to mitigate risk for TRALI have been implemented worldwide and they continued to evolve with time. The AABB requires that all plasma containing components and whole blood for transfusion must be collected from men, women who have not been pregnant, or women who have tested negative for human leucocyte antigen antibodies. Although the incidence of TRALI has decreased following the institution of TRALI mitigation strategies, TRALI is still the most common cause of transfusion-associated death in the United States. In this review, we focus on TRALI risk mitigation strategies. We describe the measures taken by blood collection facilities to reduce the risk of TRALI in the United States, Canada and European countries. We also review the literature for the effectiveness of these measures.
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Affiliation(s)
- Z K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI, USA
| | - C Liu
- Department of Pathology and Immunology, Barnes-Jewish Hospital, Washington University, St Louis, MO, USA
| | - B J Grossman
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI, USA
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Abstract
Guillain-Barré syndrome has been reported in pregnancy and is a potentially lethal condition. It affects the nervous system with acute onset of symmetric ascending weakness and may result in frank respiratory failure and autonomic dysfunction. Most patients recall symptoms of a respiratory or gastrointestinal illness in the weeks preceding the onset of weakness. Recent evidence suggests a potential role of the Zika virus as a trigger for the syndrome. The diagnosis of Guillain-Barré is clinical. Supportive measures include venous thromboembolism prophylaxis, aggressive physical therapy, pressure ulcer prevention, enteral nutrition, and respiratory support. The mainstay of management comprises plasmapheresis or administration of intravenous immunoglobulins. Affected patients must be closely monitored for development of respiratory failure and autonomic dysfunction. Treatment during pregnancy should follow the same principles as for nonpregnant individuals.
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Ravindranath MH. HLA Class Ia and Ib Polyreactive Anti-HLA-E IgG2a Monoclonal Antibodies (TFL-006 and TFL-007) Suppress Anti-HLA IgG Production by CD19+ B Cells and Proliferation of CD4+ T Cells While Upregulating Tregs. J Immunol Res 2017; 2017:3475926. [PMID: 28634589 PMCID: PMC5467321 DOI: 10.1155/2017/3475926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/18/2017] [Accepted: 03/23/2017] [Indexed: 12/20/2022] Open
Abstract
The anti-HLA-E IgG2a mAbs, TFL-006 and TFL-007, reacted with all HLA-I antigens, similar to the therapeutic preparations of IVIg. Indeed, IVIg lost its HLA reactivity, when its HLA-E reactivity was adsorbed out. US-FDA approved IVIg to reduce antibodies in autoimmune diseases. But the mechanism underlying IVIg-mediated antibody reduction could not be ascertained due to the presence of other polyclonal antibodies. In spite of it, the cost prohibitive high or low IVIg is administered to patients waiting for donor organ and for allograft recipients for lowering antiallograft antibodies. A mAb that could mimic IVIg in lowering Abs, with defined mechanism of action, would be highly beneficial for patients. Demonstrably, the anti-HLA-E mAbs mimicked several functions of IVIg relevant to suppressing the antiallograft Abs. The mAbs suppressed activated T cells and anti-HLA antibody production by activated B cells, which were dose-wise superior to IVIg. The anti-HLA-E mAb expanded CD4+, CD25+, and Foxp3+ Tregs, which are known to suppress T and B cells involved in antibody production. These defined functions of the anti-HLA-E IgG2a mAbs at a level superior to IVIg encourage developing their humanized version to lower antibodies in allograft recipients, to promote graft survival, and to control autoimmune diseases.
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Borders CF, Suzuki Y, Lasky J, Schaufler C, Mallem D, Lee J, Carney K, Bellamy SL, Bermudez CA, Localio AR, Christie JD, Diamond JM, Cantu E. Massive donor transfusion potentially increases recipient mortality after lung transplantation. J Thorac Cardiovasc Surg 2017; 153:1197-1203.e2. [PMID: 28073574 PMCID: PMC5392422 DOI: 10.1016/j.jtcvs.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 11/18/2016] [Accepted: 12/04/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Donor blood transfusion has been identified as a potential risk factor for primary graft dysfunction and by extension early mortality. We sought to define the contributing risk of donor transfusion on early mortality for lung transplant. METHODS Donor and recipient data were abstracted from the Organ Procurement and Transplantation Network database updated through June 30, 2014, which included 86,398 potential donors and 16,255 transplants. Using the United Network for Organ Sharing 4-level designation of transfusion (no blood, 1-5 units, 6-10 units, and >10 units, massive), we analyzed all-cause mortality at 30-days with the use of logistic regression adjusted for confounders (ischemic time, donor age, recipient diagnosis, lung allocation score and recipient age, and recipient body mass index). Secondary analyses assessed 90-day and 1-year mortality and hospital length of stay. RESULTS Of the 16,255 recipients transplanted, 8835 (54.35%) donors received at least one transfusion. Among those transfused, 1016 (6.25%) received a massive transfusion, defined as >10 units. Those donors with massive transfusion were most commonly young trauma patients. After adjustment for confounding variables, donor massive transfusion was associated significantly with an increased risk in 30-day (P = .03) and 90-day recipient mortality (P = .01) but not 1-year mortality (P = .09). There was no significant difference in recipient length of stay or hospital-free days with respect to donor transfusion. CONCLUSIONS Massive donor blood transfusion (>10 units) was associated with early recipient mortality after lung transplantation. Conversely, submassive donor transfusion was not associated with increased recipient mortality. The mechanism of increased early mortality in recipients of lungs from massively transfused donors is unclear and needs further study but is consistent with excess mortality seen with primary graft dysfunction in the first 90 days posttransplant.
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Affiliation(s)
- Catherine F Borders
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Yoshikazu Suzuki
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Jared Lasky
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Christian Schaufler
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Djamila Mallem
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - James Lee
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Kevin Carney
- Transplant Institute, University of Pennsylvania, Philadelphia, Pa
| | - Scarlett L Bellamy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - A Russell Localio
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
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Gürcan HM, Ahmed AR. Frequency of Adverse Events Associated with Intravenous Immunoglobulin Therapy in Patients with Pemphigus or Pemphigoid. Ann Pharmacother 2016; 41:1604-10. [PMID: 17785614 DOI: 10.1345/aph.1k198] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Intravenous immunoglobulin (IVIG) therapy is widely used in immune-mediated diseases as an immunomodulatory agent and is considered to be a safe biologic agent. Objective: To determine the frequency of adverse events associated with IVIG therapy in patients with pemphigus and pemphigoid. Methods: We retrospectively reviewed data on patients treated with IVIG for pemphigus and pemphigoid over a 10 year period. Patients had pemphigus vulgaris, pemphigus foliaceus, mucous membrane pemphigoid, or bullous pemphigoid. IVIG was given according to a published protocol at a dose of 2 g/kg administered over 3–5 days at prescribed intervals. Patient records were reviewed for information on sex, age, duration of treatment, number of cycles given, number of days each patient received IVIG, weight of each patient, IVIG dose each patient received per infusion, and early or delayed adverse effects reported by patients or observed by healthcare providers. Results: We identified 9892 infusions given to 174 patients. Headaches were the most common adverse effects; they were observed during 886 (8.9%) infusions and involved 123 (70.6%) patients. The incidence of other minor adverse effects, including fatigue, nausea, vomiting, chills, urticaria, swollen glands, hoarseness, thoracic discomfort, and palpitations, was 0.57–3.4% per infusion and 0.04–1,3% per patient. Hoarseness of voice and swelling of cervical lymph nodes have not been previously reported. Acute renal failure occurred in one patient and was the only major adverse effect observed. None of the patients required hospitalization, and there were no deaths. Conclusions: Adverse events associated with IVIG therapy are usually mild and self-limiting. The incidence of serious adverse events is low. Identification of risk factors and close monitoring of high-risk patients throughout the therapy are likely to decrease the occurrence of rare serious and less likely fatal adverse effects.
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Affiliation(s)
- Hakan M Gürcan
- Department of Medicine, Center for Blistering Diseases, New England Baptist Hospital, Boston, MA 02120, USA
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25
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Kumar R, Sedky MJ, Varghese SJ, Sharawy OE. Transfusion Related Acute Lung Injury (TRALI): A Single Institution Experience of 15 Years. Indian J Hematol Blood Transfus 2016; 32:320-7. [PMID: 27429525 PMCID: PMC4930763 DOI: 10.1007/s12288-015-0604-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 09/24/2015] [Indexed: 10/23/2022] Open
Abstract
Transfusion related acute Lung injury (TRALI) though a serious blood transfusion reaction with a fatality rate of 5-25 % presents with acute respiratory distress with hypoxaemia and noncardiac pulmonary oedema within 6 h of transfusion. In non fatal cases, it may resolve within 72 h or earlier. Although reported with an incidence of 1:5000, its true occurrence is rather unknown. Pathogenesis is believed to be related to sequestration and adhesion of neutrophils to the pulmonary capillary endothelium and its activation leading to its destruction and leaks. The patient's underlying condition, anti-neutrophil antibody in the transfused donor plasma and certain lipids that accumulate in routinely stores blood and components are important in its aetiopathogenesis. Patient's predisposing conditions include haematological malignancy, major surgery (especially cardiac), trauma and infections. The more commonly incriminated products include fresh frozen plasma (FFP), platelets (whole blood derived and apheresis), whole blood and Packed RBC. Occasional cases involving cryoprecipitate and Intravenous immunoglobulin (IVig) have also been reported. We present a 15 year single institution experience of TRALI, during which we observed 9 cases among 170,871 transfusions, giving an incidence of 1:19,000. We did not encounter cases of haematological malignancy or cardiac surgery in our TRALI patients. Among the blood products, that could be related to TRALI in our patients included solitary cases receiving cryoprecipitate, IVIg, and recombinant Factor VII apart from platelets and FFP. All patients were treated with oxygen support. Six patients required mechanical ventilation. Off label hydrocortisone was given to all patients. There were no cases of fatality among our patients.
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Affiliation(s)
- Ramesh Kumar
- />Department of Hematology, Al Adan Hospital Kuwait, Al Fintas, Kuwait
| | - Mohammed Jaber Sedky
- />Hematologists, Therapeutic Apheresis Division, Kuwait Central Blood Bank, Jabriya, Kuwait
| | - Sunny Joseph Varghese
- />Consultant Hematology and Blood Bank, YADC, Al Adan Hospital Complex, PB 1276, 51013 Al Fintas, Kuwait
| | - Osama Ebrahim Sharawy
- />Hematologists, Therapeutic Apheresis Division, Kuwait Central Blood Bank, Jabriya, Kuwait
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Anh-Tu Hoa S, Hudson M. Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies. Semin Arthritis Rheum 2016; 46:488-508. [PMID: 27908534 DOI: 10.1016/j.semarthrit.2016.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research. METHODS Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form. RESULTS The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM. CONCLUSION Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.
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Affiliation(s)
- Sabrina Anh-Tu Hoa
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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Abstract
BACKGROUND A 26-year-old female with myasthenic crisis developed transfusion-related acute lung injury (TRALI) after she was treated with intravenous immunoglobulin. METHODS Case report. RESULTS Respiratory status markedly worsened with each intravenous immunoglobulin (IVIG) administration and progressing from a need to use bilevel positive airway pressure (BiPAP) to intubation. Pulmonary function tests improved during this episode. CONCLUSIONS IVIG may cause TRALI and due to subtle clinical findings can be mistaken for neuromuscular respiratory failure.
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West FB, Kelher MR, Silliman CC. Red Blood Cell Transfusion. TRAUMA INDUCED COAGULOPATHY 2016. [PMCID: PMC7178873 DOI: 10.1007/978-3-319-28308-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Blood is classified as a drug and transfusion is one of the most commonly performed procedures in the USA. General knowledge of blood manufacturing, shelf life and storage media, common component modifications, blood types, and product compatibility allows the clinician to better communicate their needs and to understand what options may be available when ordering blood products. All transfusions offer benefits, and the clinician must comprehend the possible adverse events, especially those related to TRALI, which continues to be the most common cause of transfusion-related death reported to FDA, with TACO as the second most-commonly reported event. Transfusing in the setting of hemorrhagic blood loss adds additional challenges regarding volume overload, coagulopathy, and optimum transfusion ratios of red cells, plasma, platelets, and cryoprecipitate. The information imparted in this chapter will help equip the clinician with the knowledge needed to make the best decisions for patients requiring blood products, especially injured patients.
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Management of adverse events in the treatment of patients with immunoglobulin therapy: A review of evidence. Autoimmun Rev 2015; 15:71-81. [PMID: 26384525 DOI: 10.1016/j.autrev.2015.09.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 12/12/2022]
Abstract
Immunoglobulin (IG) therapy is actually used for a broad range of diseases including primary and secondary immunodeficiency disorders, and autoimmune diseases. This therapy is available for intravenous (IV) and subcutaneous (SC) administration. The efficacy of the IG therapy has been demonstrated in numerous studies and across different diseases. Generally, IG infusions are well tolerated; however some well-known adverse reactions, ranging from mild to severe, are associated with the therapy. The most common adverse reactions including headache, nausea, myalgia, fever, chills, chest discomfort, skin and anaphylactic reactions, could arise immediately during or after the infusion. Delayed events could be more severe and include migraine headaches, aseptic meningitis, haemolysis renal impairment and thrombotic events. This paper reviews all the potential adverse events related to IG therapy and establishes a comprehensive guideline for the management of these events. Moreover it resumes the opinions and clinical experience of expert endorsers on the utilization of the treatment. Published data were classified into levels of evidence and the strength of the recommendation was given for each intervention according to the GRADE system.
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Kim J, Na S. Transfusion-related acute lung injury; clinical perspectives. Korean J Anesthesiol 2015; 68:101-5. [PMID: 25844126 PMCID: PMC4384395 DOI: 10.4097/kjae.2015.68.2.101] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/06/2015] [Accepted: 02/09/2015] [Indexed: 02/07/2023] Open
Abstract
Transfusion-related acute lung injury (TRALI) was introduced in 1983 to describe a clinical syndrome seen within 6 h of a plasma-containing blood products transfusion. TRALI is a rare transfusion complication; however, the FDA has suggested that TRALI is the leading cause of transfusion-related mortality. Understanding the pathogenesis of TRALI will facilitate adopting preventive strategies, such as deferring high plasma volume female product donors. This review outlines the clinical features, pathogenesis, treatment, and prevention of TRALI.
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Affiliation(s)
- Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea. ; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea. ; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Stein MR. The New Generation of Liquid Intravenous Immunoglobulin Formulations in Patient Care: A Comparison of Intravenous Immunoglobulins. Postgrad Med 2015; 122:176-84. [DOI: 10.3810/pgm.2010.09.2214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ravindranath MH, Terasaki PI, Maehara CY, Jucaud V, Kawakita S, Pham T, Yamashita W. Immunoglobulin (Ig)G purified from human sera mirrors intravenous Ig human leucocyte antigen (HLA) reactivity and recognizes one's own HLA types, but may be masked by Fab complementarity-determining region peptide in the native sera. Clin Exp Immunol 2015; 179:309-28. [PMID: 25196542 DOI: 10.1111/cei.12450] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 01/19/2023] Open
Abstract
Intravenous immunoglobulin (IVIg) reacted with a wide array of human leucocyte antigen (HLA) alleles, in contrast to normal sera, due possibly to the purification of IgG from the pooled plasma. The reactivity of IgG purified from normal sera was compared with that of native sera to determine whether any serum factors mask the HLA reactivity of anti-HLA IgG and whether IgG purified from sera can recognize the HLA types of the corresponding donors. The purified IgG, unlike native sera, mirrored IVIg reactivity to a wide array of HLA-I/-II alleles, indicating that anti-HLA IgG may be masked in normal sera - either by peptides derived from soluble HLA or by those from antibodies. A < 3 kDa peptide from the complementarity-determining region (CDR) of the Fab region of IgG (but not the HLA peptides) masked HLA recognition by the purified IgG. Most importantly, some of the anti-HLA IgG purified from normal sera - and serum IgG from a few donors - indeed recognized the HLA types of the corresponding donors, confirming the presence of auto-HLA antibodies. Comparison of HLA types with the profile of HLA antibodies showed auto-HLA IgG to the donors' HLA antigens in this order of frequency: DPA (80%), DQA (71%), DRB345 (67%), DQB (57%), Cw (50%), DBP (43%), DRB1 (21%), A (14%) and B (7%). The auto-HLA antibodies, when unmasked in vivo, may perform immunoregulatory functions similar to those of therapeutic preparations of IVIg.
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Zülfikar B, Koç B. Use of intravenous immunoglobulin in pediatric practice. TURK PEDIATRI ARSIVI 2014; 49:282-8. [PMID: 26078679 PMCID: PMC4462316 DOI: 10.5152/tpa.2014.2212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/24/2014] [Indexed: 12/13/2022]
Abstract
In recent years, human-driven intravenous immunoglobulins (IVIG) administered intravenously have been widely used in treatment of many diseases. Intravenous immunoglobulin is obtained from human-driven plasma pools as in other plasma-driven products and IVIG preperations contain structurally and functionally intact immunoglobulin. Intravenous immunoglobulin was approved by FDA (Food and Drug Administration) in USA in 1981 for the first time and was started to be primarily used in patients with immune deficiency with hypogammaglobulinemia. The effects of intravenous immunoglobulin include complex mechanisms, but it exerts its essential action by eliminating the non-specific Fc receptors found in the mononuclear phagocytic system or by inhibiting binding of immune complexes to Fc receptors in the cells. Their areas of usage include conditions where their anti-inflammatory and immunomudulator effects are utilized in addition to replacement of deficient immunoglobulin. Although the definite indications are limited, it has been shown that it is useful in many diseases in clinical practice. Its side effects include fever, sweating, nausea, tachycardia, eczematous reactions, aseptic meningitis, renal failure and hematological-thromboembolic events. In this article, use of IVIG, its mechanisms of action, indications and side effects were discussed.
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Affiliation(s)
- Bülent Zülfikar
- Division of Pediatric Hematology-Oncology, İstanbul University, Cerrahpaşa Medical Faculty and Oncology Institute, İstanbul, Turkey
| | - Başak Koç
- Division of Pediatric Hematology-Oncology, İstanbul University, Cerrahpaşa Medical Faculty and Oncology Institute, İstanbul, Turkey
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Germishuizen WA, Gyure DC, Stubbings D, Burnouf T. Quantifying the thrombogenic potential of human plasma-derived immunoglobulin products. Biologicals 2014; 42:260-70. [PMID: 25096922 DOI: 10.1016/j.biologicals.2014.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/24/2014] [Accepted: 04/29/2014] [Indexed: 12/27/2022] Open
Abstract
Polyvalent immunoglobulin G (IgG) products obtained by fractionation of human plasma are used to treat a broad range of conditions, including immunodeficiency syndromes and autoimmune, inflammatory, and infectious diseases. Recent incidences of increased thromboembolic events (TEEs) associated with intravenous (IV) IgG (IVIG) led to recalls of some products and increased regulatory oversight of manufacturing processes in order to ensure that products are essentially free of procoagulant/thrombogenic plasma protein contaminants. Laboratory investigations have now identified activated factor XI (FXIa) as the likely causative agent of IVIG-related TEEs. Quantification of the thrombogenic potential is becoming a requirement made to fractionators (a) to validate the capacity of IVIG and subcutaneous IgG manufacturing processes to remove procoagulant contaminants and (b) to establish the safety of the final products. However, in the absence of a recommended test by the main regulatory authorities, several analytical approaches have been evaluated by fractionators, regulators, and university groups. This review focuses on the scientific rationale, merits, and applications of several analytical methods of quantifying the thrombogenic potential of IgG products and intermediates to meet the latest regulatory requirements.
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Affiliation(s)
| | - D C Gyure
- National Bioproducts Institute, Pinetown, South Africa
| | - D Stubbings
- National Bioproducts Institute, Pinetown, South Africa
| | - T Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, Taipei Medical University, 250 Wuxing St., Taipei City 110, Taiwan.
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Quest GR, Gaal H, Clarke G, Nahirniak S. Transfusion-related acute lung injury after transfusion of pooled immune globulin: a case report. Transfusion 2014; 54:3088-91. [PMID: 24898568 DOI: 10.1111/trf.12731] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transfusion-related acute lung injury (TRALI) is a severe transfusion reaction that manifests as acute respiratory compromise within 6 hours of the infusion of blood products. Intravenous immune globulin (IVIG) is prepared from large pools of human plasma and is commonly administered in the outpatient setting for the treatment of a wide range of diseases. As a plasma-derived blood product, IVIG may also cause TRALI, although reports of this are exceedingly rare. CASE REPORT A 77-year-old female with common variable immune deficiency had been receiving IVIG since 1996 for infection prophylaxis. During a scheduled infusion, the patient developed hypertension and dyspnea, requiring increasing oxygen supplementation and subsequent intubation. Radiographic studies demonstrated the bilateral chest infiltrates, with no evidence of infection or circulatory overload. The patient was extubated after 24 hours and discharged several days later. The patient had not previously received this lot of IVIG and has since received further transfusions with different lot numbers of the same product without incident. CONCLUSION This case report documents a case of TRALI after IVIG transfusion. While a very rare cause, this case furthers evidence that TRALI can occur after IVIG transfusion.
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Affiliation(s)
- Graeme R Quest
- Transfusion Medicine, Edmonton Zone, Alberta Health Services, Edmonton, Alberta, Canada; Laboratory Medicine and Pathology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Choi YH, Lee BJ, Park JD, Kim SH. Kawasaki Disease with Acute Respiratory Distress Syndrome after Intravenous Immunoglobulin Infusion. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.4.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yu Hyeon Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bong Jin Lee
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyo Kim
- Department of Pediatrics, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
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37
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Berger M. Adverse effects of IgG therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2013; 1:558-66. [PMID: 24565701 DOI: 10.1016/j.jaip.2013.09.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/18/2013] [Accepted: 09/19/2013] [Indexed: 11/29/2022]
Abstract
IgG is widely used for patients with immune deficiencies and in a broad range of autoimmune and inflammatory disorders. Up to 40% of intravenous infusions of IgG may be associated with adverse effects (AEs), which are mostly uncomfortable or unpleasant but often are not serious. The most common infusion-related AE is headache. More serious reactions, including true anaphylaxis and anaphylactoid reactions, occur less frequently. Most reactions are related to the rate of infusion and can be prevented or treated just by slowing the infusion rate. Medications such as nonsteroidal anti-inflammatory drugs, antihistamines, or corticosteroids also may be helpful in preventing or treating these common AEs. IgA deficiency with the potential of IgG or IgE antibodies against IgA increases the risk of some AEs but should not be viewed as a contraindication if IgG therapy is needed. Potentially serious AEs include renal dysfunction and/or failure, thromboembolic events, and acute hemolysis. These events usually are multifactorial, related to combinations of constituents in the IgG product as well as risk factors for the recipient. Awareness of these factors should allow minimization of the risks and consequences of these AEs. Subcutaneous IgG is absorbed more slowly into the circulation and has a lower incidence of AEs, but awareness and diligence are necessary whenever IgG is administered.
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Affiliation(s)
- Melvin Berger
- Immunology Research and Development, CSL Behring, LLC, King of Prussia, Pa.
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38
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Angaswamy N, Tiriveedhi V, Sarma NJ, Subramanian V, Klein C, Wellen J, Shenoy S, Chapman WC, Mohanakumar T. Interplay between immune responses to HLA and non-HLA self-antigens in allograft rejection. Hum Immunol 2013; 74:1478-85. [PMID: 23876679 DOI: 10.1016/j.humimm.2013.07.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 07/09/2013] [Accepted: 07/09/2013] [Indexed: 01/02/2023]
Abstract
Recent studies strongly suggest an increasing role for immune responses against self-antigens (Ags) which are not encoded by the major histocompatibility complex in the immunopathogenesis of allograft rejection. Although, improved surgical techniques coupled with improved methods to detect and avoid sensitization against donor human leukocyte antigen (HLA) have improved the immediate and short term function of transplanted organs. However, acute and chronic rejection still remains a vexing problem for the long term function of the transplanted organ. Immediately following organ transplantation, several factors both immune and non immune mechanisms lead to the development of local inflammatory milieu which sets the stage for allograft rejection. Traditionally, development of antibodies (Abs) against mismatched donor HLA have been implicated in the development of Ab mediated rejection. However, recent studies from our laboratory and others have demonstrated that development of humoral and cellular immune responses against non-HLA self-Ags may contribute in the pathogenesis of allograft rejection. There are reports demonstrating that immune responses to self-Ags especially Abs to the self-Ags as well as cellular immune responses especially through IL17 has significant pro-fibrotic properties leading to chronic allograft failure. This review summarizes recent studies demonstrating the role for immune responses to self-Ags in allograft immunity leading to rejection as well as present recent evidence suggesting there is interplay between allo- and autoimmunity leading to allograft dysfunction.
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Affiliation(s)
- Nataraju Angaswamy
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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39
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Stiehm ER. Adverse effects of human immunoglobulin therapy. Transfus Med Rev 2013; 27:171-8. [PMID: 23835249 DOI: 10.1016/j.tmrv.2013.05.004] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 04/08/2013] [Accepted: 05/21/2013] [Indexed: 01/20/2023]
Abstract
Human immunoglobulin (IG) is used for IgG replacement therapy in primary and secondary immunodeficiency, for prevention and treatment of certain infections, and as an immunomodulatory agent for autoimmune and inflammatory disorders. IG has a wide spectrum of antibodies to microbial and human antigens. Several high-titered IGs are also available enriched in antibodies to specific viruses or bacterial toxins. IG can be given intravenously (IGIV), intramuscularly (IGIM) or by subcutaneous infusions (SCIG). Local adverse reactions such as persistent pain, bruising, swelling and erythema are rare with IGIV infusions but common (75%) with SCIG infusions. By contrast, adverse systemic reactions are rare with SCIG infusions but common with IGIV infusions, occurring as often as 20% to 50% of patients and 5% to 15% of all IGIV infusions. Systemic adverse reactions can be immediate (60% of reactions) occurring within 6 hours of an infusion, delayed (40% of reactions) occurring 6 hours-1 week after an infusion, and late (less than 1% of reactions), occurring weeks and months after an infusion. Immediate systemic reactions such as head and body aches, chills and fever are usually mild and readily treatable. Immediate anaphylactic and anaphylactoid reactions are uncommon. The most common delayed systemic reaction is persistent headache. Less common but more serious delayed reactions include aseptic meningitis, renal failure, thromboembolism, and hemolytic reactions. Late reactions are uncommon but often severe, and include lung disease, enteritis, dermatologic disorders and infectious diseases. The types, incidence, causes, prevention, and management of these reactions are discussed.
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Affiliation(s)
- E Richard Stiehm
- Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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40
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Ravindranath MH, Terasaki PI, Pham T, Jucaud V, Kawakita S. Therapeutic preparations of IVIg contain naturally occurring anti-HLA-E antibodies that react with HLA-Ia (HLA-A/-B/-Cw) alleles. Blood 2013; 121:2013-28. [PMID: 23305735 DOI: 10.1182/blood-2012-08-447771] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The US Food and Drug Administration approved intravenous immunoglobulin (IVIg), extracted from the plasma of thousands of blood donors, for removing HLA antibodies (Abs) in highly sensitized patients awaiting organ transplants. Since the blood of healthy individuals has HLA Abs, we tested different IVIg preparations for reactivity to HLA single antigen Luminex beads. All preparations showed high levels of HLA-Ia and -Ib reactivity. Since normal nonalloimmunized males have natural antibodies to the heavy chains (HCs) of HLA antigens, the preparations were then tested against iBeads coated only with intact HLA antigens. All IVIg preparations varied in level of antibody reactivity to intact HLA antigens. We raised monoclonal Abs against HLA-E that mimicked IVIg's HLA-Ia and HLA-Ib reactivity but reacted only to HLA-I HCs. Inhibition experiments with synthetic peptides showed that HLA-E shares epitopes with HLA-Ia alleles. Importantly, depleting anti-HLA-E Abs from IVIg totally eliminated the HLA-Ia reactivity of IVIg. Since anti-HLA-E mAbs react with HLA-Ia, they might be useful in suppressing HLA antibody production, similar to the way anti-RhD Abs suppress production. At the same time, anti-HLA-E mAb, which reacts only to HLA-I HCs, is unlikely to produce transfusion-related acute lung injury, in contrast to antibodies reacting to intact-HLA.
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41
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Abstract
Three transfusion complications are responsible for the majority of the morbidity and mortality in hospitalized patients. This article discusses the respiratory complications associated with these pathophysiologic processes, including definitions, diagnosis, mechanism, incidence, risk factors, clinical management, and strategies for prevention. It also explores how different patient populations and different blood components differentially affect the risk of these deadly transfusion complications. Lastly, the article discusses how health care providers can risk stratify individual patients or patient populations to determine whether a given transfusion is more likely to benefit or harm the patient based on the transfusion indication, risk, and expected result.
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Affiliation(s)
- Alexander B Benson
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, 12700 East 19th Avenue, Aurora, CO 80045, USA.
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42
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Kim HH, Lee DK, Park CY, Ju JK, Kim JC. Transfusion-Related Acute Lung Injury after Stored Packed Red Blood Cell Transfusion - A Case Report -. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.2.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ho-Hyun Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Kyu Lee
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Chan-Yong Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Kyoon Ju
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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43
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Stoclin A, Delbos F, Dauriat G, Brugière O, Boeri N, Métivier AC, Thabut G, Camus P, Mal H. Transfusion-related acute lung injury after intravenous immunoglobulin treatment in a lung transplant recipient. Vox Sang 2012; 104:175-8. [PMID: 22985417 DOI: 10.1111/j.1423-0410.2012.01645.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Three weeks after single-lung transplantation for pulmonary fibrosis, a patient with high serum levels of de novo donor-specific antibodies received high-dose intravenous immunoglobulin (IVIG) infusion (scheduled dose: 2 g/kg on 2 days) to prevent antibody-mediated rejection. Within the first hours after completion of infusions, he experienced acute lung injury involving the transplanted lung. Given the clinical evolution and the absence of an alternative diagnosis, transfusion-related acute lung injury (TRALI) was diagnosed. The IVIG administered on each day was from the same batch. At day 110, because of an increase in the serum titers of donor-specific antibodies, IVIG therapy was reintroduced but from a different batch, with excellent clinical tolerance. The lung injury was explored biologically, but no mechanism was revealed. Given the increasing use of IVIG in solid-organ recipients, clinicians should be aware of possible TRALI after IVIG infusion.
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Affiliation(s)
- A Stoclin
- Service de Pneumologie et de Transplantation Pulmonaire, Hôpital Bichat, Assistance Publique Hôpitaux de Paris, Université Denis Diderot, Paris France
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44
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Semple JW, Kim M, Hou J, McVey M, Lee YJ, Tabuchi A, Kuebler WM, Chai ZW, Lazarus AH. Intravenous immunoglobulin prevents murine antibody-mediated acute lung injury at the level of neutrophil reactive oxygen species (ROS) production. PLoS One 2012; 7:e31357. [PMID: 22363629 PMCID: PMC3281967 DOI: 10.1371/journal.pone.0031357] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 01/06/2012] [Indexed: 01/06/2023] Open
Abstract
Transfusion-related acute lung injury (TRALI) is a leading cause of transfusion-associated mortality that can occur with any type of transfusion and is thought to be primarily due to donor antibodies activating pulmonary neutrophils in recipients. Recently, a large prospective case controlled clinical study of cardiac surgery patients demonstrated that despite implementation of male donors, a high incidence of TRALI still occurred and suggested a need for additional interventions in susceptible patient populations. To examine if intravenous immunoglobulin (IVIg) may be effective, a murine model of antibody-mediated acute lung injury that approximates human TRALI was examined. When BALB/c mice were injected with the anti-major histocompatibility complex class I antibody 34-1-2s, mild shock (reduced rectal temperature) and respiratory distress (dyspnea) were observed and pre-treatment of the mice with 2 g/kg IVIg completely prevented these symptoms. To determine IVIg's usefulness to affect severe lung damage, SCID mice, previously shown to be hypersensitive to 34-1-2s were used. SCID mice treated with 34-1-2s underwent severe shock, lung damage (increased wet/dry ratios) and 40% mortality within 2 hours. Treatment with 2 g/kg IVIg 18 hours before 34-1-2s administration completely protected the mice from all adverse events. Treatment with IVIg after symptoms began also reduced lung damage and mortality. While the prophylactic IVIg administration did not affect 34-1-2s-induced pulmonary neutrophil accumulation, bone marrow-derived neutrophils from the IVIg-treated mice displayed no spontaneous ROS production nor could they be stimulated in vitro with fMLP or 34-1-2s. These results suggest that IVIg prevents murine antibody-mediated acute lung injury at the level of neutrophil ROS production and thus, alleviating tissue damage.
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Affiliation(s)
- John W. Semple
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Blood Services, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michael Kim
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jing Hou
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark McVey
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Young Jin Lee
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Arata Tabuchi
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Wolfgang M. Kuebler
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Zhong-Wei Chai
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan H. Lazarus
- The Toronto Platelet Immunobiology Group, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Blood Services, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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45
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Abstract
Red blood cell transfusion (RBCT) is a common therapy used in the intensive care unit to treat anemia. However, due to deleterious side effects and questionable efficacy, the clinical benefit of RBCT in patients who are not actively bleeding is unclear. The results of randomized controlled trials suggest there is no benefit to a liberal transfusion practice in general critical care populations. Whether the results of these trials are applicable to brain injured patients is unknown, as patients with primary neurological injury were excluded. This article reviews the efficacy and complications of RBCT, as well as the relationship between RBCT and its outcome in both the general intensive care unit and neurologically critically ill populations.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA.
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46
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Despotovic JM, Lambert MP, Herman JH, Gernsheimer TB, McCrae KR, Tarantino MD, Bussel JB. RhIG for the treatment of immune thrombocytopenia: consensus and controversy (CME). Transfusion 2011; 52:1126-36; quiz 1125. [PMID: 21981825 DOI: 10.1111/j.1537-2995.2011.03384.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anti-D immune globulin (RhIG) is a front-line option in North America for the treatment of immune thrombocytopenia (ITP) in children and adults. Recently, addition of a Food and Drug Administration-mandated black box warning highlighted the risks of intravascular hemolysis, renal failure, and disseminated intravascular coagulation after anti-D infusion, prompting concern within the medical community regarding its use. A working group convened in response to this warning to prepare a consensus document regarding the safety of RhIG because there has been no increased incidence of adverse events since the initial discovery of these reactions many years ago. The efficacy of anti-D is well documented and only briefly reviewed. The estimated incidence and proposed mechanisms for the rare, major treatment-related complications are discussed, and signal detection data associated with heightened risk of acute hemolytic reactions are presented. The importance of considering host factors, given the rarity of severe reactions, is emphasized. Safety profiles of parallel treatment options are reviewed. The working group consensus is that RhIG has comparable safety and efficacy to other front-line agents for the treatment of children and adults with ITP. Safety may be further improved by careful patient selection.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX 77030, USA.
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47
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Aung FM, Cano P, Fernandez-Vina M, Lichtiger B. Results of HLA antibody testing using ELISA vs the fluorescent bead method and retrospective review of data for recipients of packed RBCs and platelets from male HLA-immunized donors. Am J Clin Pathol 2011; 135:90-5. [PMID: 21173129 DOI: 10.1309/ajcp98jnyhgcgmhk] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We reviewed HLA antibody testing results using an enzyme-linked immunosorbent assay (ELISA) for all male blood donors at our institution during a 3.5-month period to look for HLA immunization. Confirmatory testing of 33 blood samples positive for HLA class I and/or II antibodies was performed using the fluorescent bead method. A retrospective review of recipients of packed RBCs and platelets processed from these 33 HLA-immunized male donors were conducted to identify transfusion-related acute lung injury and cognate antigens. The agreement rates between the methods for HLA class I and II antibodies were 21% (7/33) and 6% (2/33), respectively. We noted HLA antibodies in the male donors corresponding to cognate antigens in 2 recipients of packed RBCs and in 3 recipients of platelets. Of 8 donors positive for HLA antibodies, 5 did not have a history of blood transfusion. We conclude that ELISA was too sensitive and had a high false-positive rate for the detection of HLA class II antibodies.
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48
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Abstract
Transfusion-related acute lung injury (TRALI) remains the deadliest complication of transfusion. Consensus definitions of TRALI have been developed but remain controversial. Recent evidence supports a strong relationship between blood transfusion and the development of acute lung injury in the critically ill and trauma population. Plasma and platelet transfusions have been the most commonly implicated blood products. The 'two hit' model may best explain the immune and nonimmune pathogenesis of TRALI. Current treatment remains largely supportive; effective measures for decreasing the incidence of TRALI include the use of predominantly male plasma and apheresis platelets. Greater understanding of the blood component and patient risk factors for TRALI will hopefully lead to novel treatment and preventive strategies for reducing the risk of this life-threatening syndrome.
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Affiliation(s)
- Mladen Sokolovic
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY 10065, USA
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49
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Voulgari PV, Paschou S, Svarna E, Tsifetaki N, Drosos AA. Images in rheumatology. Transfusion-related acute lung injury during intravenous immunoglobulin treatment. J Rheumatol 2010; 37:190-1. [PMID: 20040637 DOI: 10.3899/jrheum.090725] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Paraskevi V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, University of Ioannina, Greece
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50
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Abstract
Transfusion-related acute lung injury is a clinical syndrome that occurs within 6 hours of transfusion. It is the leading cause of transfusion-related mortality. It presents with shortness of breath, acute pulmonary edema, fever, hypotension, or hypertension followed by hypotension. Treatment consists of respiratory support and fluid administration to support blood pressure. A majority of cases are associated with antibodies to white blood cells in the blood donor. Blood centers in the United States are currently taking measures to reduce the risk of transfusion-related acute lung injury from blood components.
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