Intravenous immunoglobulin treatment in cytopenic haematological disorders

Pembrolizumab-induced Pure Red Cell Aplasia Successfully Treated with Intravenous Immunoglobulin

We herein report a 64-year-old man who was treated with pembrolizumab for relapsed Hodgkin lymphoma. After the third administration of pembrolizumab, he showed acute anemia with a positive direct anti-globulin test. Because of the markedly erythroid hypoplasia, he was diagnosed with pure red cell aplasia (PRCA) caused by pembrolizumab. He was initially treated with prednisolone, but the reticulocytes decreased after tapering prednisolone. He then received high-dose intravenous immunoglobulin (IVIG) with prednisolone, and PRCA was successfully treated. Although the pathogenesis of PRCA caused by immune checkpoint inhibitors (CPIs) remains unclear, IVIG treatment may be effective for some steroid-refractory CPI-induced PRCA cases.

Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature

BACKGROUND

Intravenous immune globulin (IVIG) has been approved by the Food and Drug Administration (FDA) for use in 6 conditions: immune thrombocytopenic purpura (ITP), primary immunodeficiency, secondary immunodeficiency, pediatric HIV infection, Kawasaki disease, prevention of graft versus host disease (GVHD) and infection in bone marrow transplant recipients. However, most usage is for off-label indications, and for some of these comprehensive guidelines have been published.

STUDY DESIGN AND METHODS

We retrospectively reviewed all approved IVIG transfusions at Massachusetts General Hospital in 2004 to identify the current usage pattern and completed a literature review.

RESULTS

IVIG was most commonly used in the treatment of chronic neuropathy, which included chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy. For such patients, the annual cost of IVIG can exceed 50,000 dollars per patient. Other common indications were the treatment of hypogammaglobulinemia, ITP, renal transplant rejection, myasthenia gravis, Guillain-Barre syndrome, necrotizing fasciitis, autoimmune hemolytic anemia, and Kawasaki disease. IVIG was administered in a variety of other indications each representing <3% of the total treated patients.

CONCLUSION

Only a few indications account for most of the usage for IVIG. Reports concerning IVIG continue to grow at a tremendous pace but few high-quality randomized controlled trials have been reported. Randomized trials are especially needed for conditions such as CIDP, which consume large quantities of product.

Intravenous immunoglobulins in autoimmune- or parvovirus B19-mediated pure red-cell aplasia

Pure red-cell aplasia (PRCA) is defined as the absence of mature erythroid precursors in a bone marrow that otherwise exhibit normal cellularity. Acquired PRCA may occur in association with neoplasms (such as lymphoproliferative disorders), thymoma, autoimmune disorders, pregnancy, or as a consequence of chronic human parvovirus B19 (B19) infection in an immunologically incompetent host. PRCA may also develop after exposure to drugs (erythropoietin or tacrolimus). PRCA of autoimmune origin was first treated successfully with intravenous immunoglobulins (IVIg) more than 20 years ago. Since then, B19-associated PRCA in solid-organ transplant recipients and in human immunodeficiency virus (HIV)-infected patients has also been successfully treated with IVIg. Routine maintenance therapy is probably not indicated in HIV-infected patients with CD4+ counts above 300/microL, whereas repeated infusions might be necessary if CD4+ count is below 80.

Effets immunomodulateurs des immunoglobulines intraveineuses

Intravenous immunoglobulins (IVIg) are therapeutic preparations of normal human IgG obtained from pools of more than 1000 healthy blood donors. They are currently used in the treatment of a wide range of auto-immune diseases, whether associated with auto-antibodies or auto-reactive T lymphocytes, as well as in the treatment of systemic inflammatory diseases. Several mechanisms of action have been identified during the last 20 years, including: (i) modulation of Fc receptors expression on leukocytes and endothelial cells; (ii) interaction with complement proteins; (iii) modulation of cytokines and chemokines synthesis and release; (iv) modulation of cell proliferation and apoptosis; (v) remyelinisation; (vi) neutralisation of circulating autoantibodies; (vii) selection of repertoires of B and T lymphocytes; (viii) interaction with other cell-surface molecules on lymphocytes and monocytes; (ix) corticosteroid sparing. These mechanisms of action are multiple and often intricate. However, they are still little known and further investigations are warranted.

IVIG-bound IgG and IgM cloned by phage display from a healthy individual reveal the same restricted germ-line gene origin as in autoimmune thrombocytopenia

Intravenous immunoglobulin preparations (IVIG) have shown positive effects in the treatment of immune defects and autoimmune diseases. It is not clear how IVIG interacts with the components of the immune system. To investigate this, we cloned previously a large number of phage displayed IgG Fab fragments derived from three patients with autoimmune thrombocytopenia (AITP) that were specifically bound by IVIG molecules. Many of these Fabs reacted with platelets. Sequencing revealed that the most frequently used germ-line gene segments of all IVIG-bound Fabs were identical to those observed for many other autoantibodies. Particularly, the loci 3-30 or 3-30/3-30. 5, 3-23 and 3r, 3l, and 2a2 represented the most abundant genes used for the heavy (VH) and light chain V region (VL), respectively. This suggested a specific interaction of IVIG molecules with B cells that present B cell receptors derived from these germ-line genes. In the current study we determined the genetic origin of IVIG-reactive IgG and IgM cloned from a healthy person. A favoured selection of antibodies derived from the same germ-line origins as in AITP was observed. Because 3-30 and 3-23 are the most frequently rearranged VH germ-line gene segments among human B cells, our results suggest that this favoured anti-idiotypic interaction may have an important role for the development and control of the normal B cell repertoire.

Platelet-reactive IgG antibodies cloned by phage display and panning with IVIG from three patients with autoimmune thrombocytopenia

Autoimmune thrombocytopenic purpura (AITP) is a severe disease in children with a still unknown aetiology. It is not known why AITP can either be transient and self limiting or become chronic. The beneficial use of intravenous immunoglobulins (IVIG) in certain groups of AITP patients has been proven. It is, however, not clear how IVIG functions. To analyse patient-derived monoclonal IgG platelet autoantibodies that interact with IVIG in an anti-idiotypic manner, the combinatorial antibody phage display system was applied. From three different patients a large number of clones specifically reacting with IVIG molecules were derived. Many of these IVIG binders also reacted strongly with platelets in ELISA and FACS, in contrast to IVIG binders derived from a healthy individual. The heavy and light chain variable regions were sequenced and compared with each other and with databases. In all three AITP patients clones with a striking complementarity-determining region (CDR) sequence homology to each other and to many of the known anti-platelet antibodies were observed. Selected Fab-phages representing the characteristic variable regions that occurred in the investigated patients with AITP may now be used to clone potentially regulatory anti-idiotypes from healthy donors by phage display.

Genetic origin of IgG antibodies cloned by phage display and anti-idiotypic panning from three patients with autoimmune thrombocytopenia

The beneficial use of intravenous immunoglobulins (IVIG) in certain groups of patients with autoimmune thrombocytopenic purpura (AITP) has been proven. AITP is a severe disease in children with a still unknown etiology. It is not clear how IVIG functions in this and other autoimmune diseases. To analyze and compare patient-derived monoclonal IgG antibodies that are bound by IVIG in an anti-idiotypic manner, the combinatorial antibody phage display system was applied. From three different patients with AITP, a large number of clones specifically reacting with IVIG molecules were enriched. The heavy and light chain variable regions were sequenced and compared with each other and with databases. Many variable regions showed extensive replacement mutations within the complementarity-determining regions, while two were identical to germ-line genes. Our data show that the most frequently used germ-line gene loci of these IVIG binders are identical to those observed for many other autoantibodies. This implicates a specific interaction of IVIG particularly with autoantibodies and B cell receptors derived from germ-line genes that are often used for the generation of autoantibodies.

Intravenous immunoglobulin treatment in hematological diseases

In the last decade large amounts of intravenous immunoglobulin (i.v.Ig) have been used worldwide. Doubts exist as to whether this increased use is paralleled by a comparable growth of reliable data on the therapeutic effectiveness of i.v.Ig. We performed a literature search using MEDLINE from January 1981 to January 1997 and analysed articles on the use of i.v.Ig in hematological disorders and searched for published guidelines. For most hematological disorders, evidence to use i.v.Ig as first line therapy is not very strong. For many disorders no controlled trials have been performed. In published guidelines, i.v.Ig is only recommended, with a few exceptions, when other treatments have failed or are contraindicated. Therefore the increase of consumption of i.v.Ig can not be explained by an increase in established indications in hematology.

Human intravenous immunoglobulin therapy

Human intravenous immunoglobulin (hIVIG) is a preparation of normal polyspecific IgG obtained from the plasma of healthy blood donors. Although purified immunoglobulins were initially developed for treatment of primary immunodeficiency syndromes, they have since been documented to be effective in the treatment of some immune-mediated diseases such as immune-mediated thrombocytopenia purpura and autoimmune hemolytic anemia. Blockade of Fc receptors on mononuclear phagocytic cells has been proposed as the most likely mechanism for the rapid early response to hIVIG treatment. Human IVIG has been used to treat canine immune-mediated hemolytic anemia (IMHA), anemia with myelofibrosis, and immune-mediated thrombocytopenia. Doses from 0.5 to 1.5 g/kg may be effective, although most studies have used a dose of 1 g/kg. Human IVIG is administered as an intravenous infusion over 6 to 12 hours, and dogs should be carefully monitored for adverse reactions during administration. The possibility of a increased risk of thromboembolism should be considered when undertaking hIVIG treatment. The safety of multiple treatments of hIVIG has not been established. In most dogs with IMHA, benefit may be limited to short-term improvement in hematocrit, which may allow time for other treatment modalities to become effective. Dogs with nonregenerative anemia and associated myelofibrosis may have longer-term responses to hIVIG treatment.

Kawasaki disease: update on diagnosis, treatment, and a still controversial etiology

Diagnosis of Kawasaki syndrome still relies solely on clinical criteria because the etiology is unknown. However, the function and structure of different bacterial superantigens as potential pathogens are discussed. In this regard, the recent determination of the crystal structure of the toxic shock syndrome toxin-1 superantigen complexed with major histocompatibility complex class II suggests potential implications for the controversial findings concerning a role of those superantigens in Kawasaki disease. Although a specific therapy is not available, coronary complications can be significantly reduced with the help of intravenous immunoglobulin therapy combined with oral aspirin.

Soluble CD4 antigen reactivity in intravenous immunoglobulin preparations: is it specific?

Soluble CD4 antigen (sCD4) was measured in seven commercially available intravenous immunoglobulin preparations (IVIg) by means of a double determinant immunoassay (DDIA), whereby two MoAbs recognizing two distinct and spatially distant epitopes on CD4 were used to capture and detect the antigen, respectively. Preincubation of six out of seven IVIg, which were found to be apparently positive for sCD4, with mouse- and bovine-derived serum or purified immunoglobulins completely neutralized DDIA reactivity for sCD4. The inhibition was specific since it was not or only partially observed when IVIg were mixed with whole serum or purified IgG from rabbit. Extensive absorption of six IVIg on insolubilized mouse IgG (mIgG) resulted in a complete loss of reactivity. Eluted human anti-mouse antibodies (HAMA) from any of the IVIg displayed a dose-dependent binding in a DDIA, though its extent varied from one preparation to another. Western blot analysis showed that HAMA from all IVIg contained no component with a molecular weight identical with or close to that of recombinant CD4. Purified mIgG markedly influenced the sCD4 reactivity of two IVIg (Sandoglobulin and Globuman I.V.) when sCD4 was measured with a purchased 'CD4-specific Test Kit', thus suggesting that HAMA can exceed the absorbing capacity of the sample diluent. Taken as a whole, these data indicate that sCD4-based DDIA signal is mostly, if not completely, generated by the presence of human immunoglobulin with anti-mouse immunoglobulin reactivity, thus casting doubts on the actual occurrence of sCD4 in IVIg.