1
|
Ahmed AR, Kalesinskas M, Kaveri SV. Restoring immune tolerance in pemphigus vulgaris. Proc Natl Acad Sci U S A 2024; 121:e2317762121. [PMID: 38261616 PMCID: PMC10835025 DOI: 10.1073/pnas.2317762121] [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: 10/12/2023] [Accepted: 12/10/2023] [Indexed: 01/25/2024] Open
Abstract
Intravenous immunoglobulin (IVIg), a preparation of polyclonal serum IgG pooled from numerous blood donors, has been used for nearly three decades and is proving to be an efficient treatment for many autoimmune blistering diseases, including pemphigus vulgaris (PV). Despite its widespread use and therapeutic success, its mechanisms of action are not completely understood. Some of its anti-inflammatory and immunomodulatory actions have been studied. In this study, the authors present a twenty-year follow-up of 21 patients with clinical and immunopathological confirmed PV, treated with IVIg as monotherapy, according to an established published protocol. IVIg therapy produced long-term sustained, clinical, serological, and immunopathological remission. For 20 y, these patients received no drugs and experienced no disease. This observation suggests that there was the establishment of immune balance or restoration of immune regulation in these PV patients. Twelve (57%) patients experienced no relapse during follow-up. Six (29%) patients experienced a relapse due to acute stress or post-coronavirus infection and/or vaccination. Reinstitution of IVIg resulted in prompt sustained recovery. Three (14.2%) patients, in clinical and serological remission, died due to unrelated causes. No severe adverse effects from IVIg were documented in all 21 patients. The simultaneous or sequential anti-inflammatory and immunomodulatory effects of IVIg may have influenced the long-term clinical remission observed. This study provides a human prototype to examine the pathophysiology of autoimmunity and a model to study immune regulation and mechanisms that can facilitate restoring immune tolerance.
Collapse
Affiliation(s)
- A. Razzaque Ahmed
- Department of Dermatology, Center for Blistering Diseases, Tufts University School of Medicine, Boston, MA02135
| | - Mikole Kalesinskas
- Department of Dermatology, Center for Blistering Diseases, Tufts University School of Medicine, Boston, MA02135
| | - Srini V. Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, ParisF-75006, France
| |
Collapse
|
2
|
Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
Collapse
Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | | |
Collapse
|
3
|
Anang DC, Walter HAW, Lim J, Niewold I, van der Weele L, Aronica E, Eftimov F, Raaphorst J, van Schaik BDC, van Kampen AHC, van der Kooi AJ, de Vries N. B-cell receptor profiling before and after IVIG monotherapy in newly diagnosed idiopathic inflammatory myopathies. Rheumatology (Oxford) 2023; 62:2585-2593. [PMID: 36321862 PMCID: PMC10321087 DOI: 10.1093/rheumatology/keac602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/06/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To unravel B-cell receptor (BcR) characteristics in muscle tissues and peripheral blood and gain more insight into BcR repertoire changes in peripheral blood in idiopathic inflammatory myopathies (IIMs), and study how this correlates to the clinical response to IVIG. METHODS Nineteen treatment-naive patients with newly diagnosed IIM were prospectively treated with IVIG monotherapy. RNA-based BcR repertoire sequencing was performed in muscle biopsies collected before, and in peripheral blood (PB) collected before and nine weeks after IVIG treatment. Results were correlated to patients' clinical improvement based on the total improvement score (TIS). RESULTS Prior to IVIG treatment, BcR clones found in muscle tissue could be retrieved in peripheral blood. Nine weeks after IVIG treatment, new patient-specific dominant BcR clones appeared in peripheral blood while pre-treatment dominant BcR clones disappeared. The cumulative frequency of all dominant BcR clones before treatment was significantly higher in individuals who responded to IVIG compared with those who did not respond to IVIG, and correlated with a higher CK. During follow-up, a decrease in the cumulative frequency of all dominant clones correlated with a higher TIS. CONCLUSION In treatment-naive patients with newly diagnosed IIM, muscle tissue and peripheral blood share expanded BcR clones. In our study a higher cumulative frequency of dominant BcR clones in blood before treatment was associated with a higher CK and better treatment response, suggesting that response to IVIG may depend on the composition of the pre-treatment BcR repertoire.
Collapse
Affiliation(s)
| | | | - Johan Lim
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Ilse Niewold
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Genome analysis, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Linda van der Weele
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Experimental Immunology, Amsterdam Infection and Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Barbera D C van Schaik
- Bioinformatics Laboratory, Department of Epidemiology and Data science, Amsterdam Public Health Institute, Amsterdam Infection and Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Antoine H C van Kampen
- Bioinformatics Laboratory, Department of Epidemiology and Data science, Amsterdam Public Health Institute, Amsterdam Infection and Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Niek de Vries
- Correspondence to: Niek de Vries, Department of Rheumatology & Clinical Immunology and Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, PO. Box 22600, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands. E-mail:
| |
Collapse
|
4
|
Shimizu T, Iida S, Omoto K, Inui M, Nozaki T, Toma H, Takagi T, Ishida H. Case Report: Suspected Hyperacute Rejection During Living Kidney Transplantation. Transplant Proc 2023:S0041-1345(23)00267-1. [PMID: 37149471 DOI: 10.1016/j.transproceed.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND We report a case of suspected hyperacute rejection during living kidney transplantation. CASE REPORT A 61-year-old man underwent kidney transplantation in November 2019. Before the transplantation, immunologic tests revealed the presence of anti-HLA antibodies but not donor-specific HLA antibodies. The patient was intravenously administered 500 mg of methylprednisolone (MP) and basiliximab before perioperative blood flow reperfusion. After blood flow restoration, the transplanted kidney turned bright red and then blue. Hyperacute rejection was suspected. After the intravenous administration of 500 mg of MP and 30 g of intravenous immunoglobulin, the transplanted kidney gradually changed from blue to bright red. The initial postoperative urine output was good. On the 22nd day after the renal transplantation, the patient was discharged with a serum creatinine level of 2.38 mg/dL, and the function of the transplanted kidney gradually improved. CONCLUSIONS In this study, non-HLA antibodies may have been a cause of the hyperacute rejection, which was managed with additional perioperative therapies.
Collapse
Affiliation(s)
- Tomokazu Shimizu
- Department of Urology and Transplant Surgery, Toda Chuo General Hospital, Saitama, Japan; Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Shoichi Iida
- Department of Urology and Transplant Surgery, Toda Chuo General Hospital, Saitama, Japan; Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masashi Inui
- Department of Urology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Taiji Nozaki
- Department of Urology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hiroshi Toma
- Department of Urology and Transplant Surgery, Toda Chuo General Hospital, Saitama, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
5
|
Segú-Vergés C, Caño S, Calderón-Gómez E, Bartra H, Sardon T, Kaveri S, Terencio J. Systems biology and artificial intelligence analysis highlights the pleiotropic effect of IVIg therapy in autoimmune diseases with a predominant role on B cells and complement system. Front Immunol 2022; 13:901872. [PMID: 36248801 PMCID: PMC9563374 DOI: 10.3389/fimmu.2022.901872] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is used as treatment for several autoimmune and inflammatory conditions, but its specific mechanisms are not fully understood. Herein, we aimed to evaluate, using systems biology and artificial intelligence techniques, the differences in the pathophysiological pathways of autoimmune and inflammatory conditions that show diverse responses to IVIg treatment. We also intended to determine the targets of IVIg involved in the best treatment response of the evaluated diseases. Our selection and classification of diseases was based on a previously published systematic review, and we performed the disease characterization through manual curation of the literature. Furthermore, we undertook the mechanistic evaluation with artificial neural networks and pathway enrichment analyses. A set of 26 diseases was selected, classified, and compared. Our results indicated that diseases clearly benefiting from IVIg treatment were mainly characterized by deregulated processes in B cells and the complement system. Indeed, our results show that proteins related to B-cell and complement system pathways, which are targeted by IVIg, are involved in the clinical response. In addition, targets related to other immune processes may also play an important role in the IVIg response, supporting its wide range of actions through several mechanisms. Although B-cell responses and complement system have a key role in diseases benefiting from IVIg, protein targets involved in such processes are not necessarily the same in those diseases. Therefore, IVIg appeared to have a pleiotropic effect that may involve the collaborative participation of several proteins. This broad spectrum of targets and 'non-specificity' of IVIg could be key to its efficacy in very different diseases.
Collapse
Affiliation(s)
| | - Silvia Caño
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
| | | | - Helena Bartra
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Teresa Sardon
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Srini Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - José Terencio
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
| |
Collapse
|
6
|
Koslik MA, Friebus-Kardash J, Heinemann FM, Kribben A, Bräsen JH, Eisenberger U. Differential Treatment Effects for Renal Transplant Recipients With DSA-Positive or DSA-Negative Antibody-Mediated Rejection. Front Med (Lausanne) 2022; 9:816555. [PMID: 35174191 PMCID: PMC8841765 DOI: 10.3389/fmed.2022.816555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/07/2022] [Indexed: 12/22/2022] Open
Abstract
Background Antibody-mediated rejection (ABMR) is the main cause of renal allograft loss. The most common treatment strategy is based on plasmapheresis plus the subsequent administration of intravenous immunoglobulin (IVIG). Unfortunately, no approved long-term therapy is available for ABMR. The current study was designed to analyze the effect of various ABMR treatment approaches on allograft survival and to compare treatment effects in the presence or absence of donor-specific antibodies (DSAs). Methods This single-center study retrospectively analyzed 102 renal allograft recipients who had biopsy-proven ABMR after transplant. DSA was detectable in 61 of the 102 patients. Initial standard treatment of ABMR consisted of plasmapheresis (PS) or immunoadsorption (IA), followed by a single course of IVIG. In case of nonresponse or recurrence, additional immunosuppressive medications, such as rituximab, bortezomib, thymoglobulin, or eculizumab, were administered. In a second step, persistent ABMR was treated with increased maintenance immunosuppression, long-term therapy with IVIG (more than 1 year), or both. Results Overall graft survival among transplant patients with ABMR was <50% after 3 years of follow-up. Compared to the use of PS/IA and IVIG alone, the use of additional immunosuppressive medications had no beneficial effect on allograft survival (p = 0.83). Remarkably, allografts survival rates were comparable between patients treated with the combination of PS/IA and IVIG and those treated with a single administration of IVIG (p = 0.18). Renal transplant patients with ABMR but without DSAs benefited more from increased maintenance immunosuppression than did DSA-positive patients with ABMR (p = 0.01). Recipients with DSA-positive ABMR exhibited significantly better allograft survival after long-term application of IVIG for more than 1 year than did recipients with DSA-negative ABMR (p = 0.02). Conclusions The results of our single-center cohort study involving kidney transplant recipients with ABMR suggest that long-term application of IVIG is more favorable for DSA-positive recipients, whereas intensification of maintenance immunosuppression is more effective for recipients with DSA-negative ABMR.
Collapse
Affiliation(s)
- Marius Andreas Koslik
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Justa Friebus-Kardash
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, Transplantation Diagnostics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Hinrich Bräsen
- Nephropathology Unit, Hannover Medical School, Institute of Pathology, Hanover, Germany
| | - Ute Eisenberger
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- *Correspondence: Ute Eisenberger
| |
Collapse
|
7
|
Katz EA, Sunshine S, Mun C, Sarwar M, Surenkhuu B, Pradeep A, Jain S. Combinatorial therapy with immunosuppressive, immunomodulatory and tear substitute eyedrops ("Triple Play") in Recalcitrant Immunological Ocular Surface Diseases. Ocul Surf 2021; 23:1-11. [PMID: 34768002 DOI: 10.1016/j.jtos.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/24/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE The current paradigm for therapy of recalcitrant ocular surface diseases (OSD) consists of a sequential, step-up treatment approach. A combinatorial topical therapy (anti-inflammatory/immunosuppressive [steroid] with immunomodulatory [pooled human immune globulin] and tear substitute [serum]) that simultaneously targets several immunological pathways may be more efficacious. This report evaluates if the combinatorial therapy resulted in clinical benefit in patients with recalcitrant OSD. METHODS We performed a retrospective case study of patients receiving topical, preservative-free, compounded formulations of steroids, pooled human immune globulin, and serum tears. Outcome measures included visual acuity, ocular surface disease index (OSDI), ocular discomfort score, subjective global assessment (SGA), corneal staining, conjunctival redness, and slit lamp photographs. RESULTS Patients consisted of one male and 11 females ranging in age from 27 to 87 years old. Pathologies included ocular graft-versus-host disease (n = 4), Sjögren's syndrome (n = 3), ocular cicatricial pemphigoid (n = 1), pemphigus vulgaris (n = 1), peripheral ulcerative keratitis (n = 1), Stevens-Johnson syndrome (n = 1), and giant papillary conjunctivitis (n = 1). All patients were "improved" or "much improved" on SGA after combinatorial therapy. There was a clinically meaningful reduction in OSDI, ocular discomfort, corneal staining, and conjunctival injection. Additionally, three patients had improvement in their visual acuity (one from 20/400 to 20/20). Adverse effects included increased intraocular pressure in two patients, presumably due to topical steroid use. CONCLUSIONS Combinatorial therapy provides clinical benefit by reducing the symptoms and signs in recalcitrant OSD. Our study provides the rationale for performing prospective clinical trials to evaluate the efficacy of combinatorial therapy for treating recalcitrant OSD.
Collapse
Affiliation(s)
- Eitan A Katz
- The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Sarah Sunshine
- University of Maryland School of Medicine, Department of Ophthalmology and Visual Sciences, Baltimore, MD, USA; The Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christine Mun
- The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Monazzah Sarwar
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Bayasgalan Surenkhuu
- The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Anubhav Pradeep
- The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Sandeep Jain
- The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, IL, USA.
| |
Collapse
|
8
|
Dalakas MC. Update on Intravenous Immunoglobulin in Neurology: Modulating Neuro-autoimmunity, Evolving Factors on Efficacy and Dosing and Challenges on Stopping Chronic IVIg Therapy. Neurotherapeutics 2021; 18:2397-2418. [PMID: 34766257 PMCID: PMC8585501 DOI: 10.1007/s13311-021-01108-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
In the last 25 years, intravenous immunoglobulin (IVIg) has had a major impact in the successful treatment of previously untreatable or poorly controlled autoimmune neurological disorders. Derived from thousands of healthy donors, IVIg contains IgG1 isotypes of idiotypic antibodies that have the potential to bind pathogenic autoantibodies or cross-react with various antigenic peptides, including proteins conserved among the "common cold"-pre-pandemic coronaviruses; as a result, after IVIg infusions, some of the patients' sera may transiently become positive for various neuronal antibodies, even for anti-SARS-CoV-2, necessitating caution in separating antibodies derived from the infused IVIg or acquired humoral immunity. IVIg exerts multiple effects on the immunoregulatory network by variably affecting autoantibodies, complement activation, FcRn saturation, FcγRIIb receptors, cytokines, and inflammatory mediators. Based on randomized controlled trials, IVIg is approved for the treatment of GBS, CIDP, MMN and dermatomyositis; has been effective in, myasthenia gravis exacerbations, and stiff-person syndrome; and exhibits convincing efficacy in autoimmune epilepsy, neuromyelitis, and autoimmune encephalitis. Recent evidence suggests that polymorphisms in the genes encoding FcRn and FcγRIIB may influence the catabolism of infused IgG or its anti-inflammatory effects, impacting on individualized dosing or efficacy. For chronic maintenance therapy, IVIg and subcutaneous IgG are effective in controlled studies only in CIDP and MMN preventing relapses and axonal loss up to 48 weeks; in practice, however, IVIg is continuously used for years in all the aforementioned neurological conditions, like is a "forever necessary therapy" for maintaining stability, generating challenges on when and how to stop it. Because about 35-40% of patients on chronic therapy do not exhibit objective neurological signs of worsening after stopping IVIg but express subjective symptoms of fatigue, pains, spasms, or a feeling of generalized weakness, a conditioning effect combined with fear that discontinuing chronic therapy may destabilize a multi-year stability status is likely. The dilemmas of continuing chronic therapy, the importance of adjusting dosing and scheduling or periodically stopping IVIg to objectively assess necessity, and concerns in accurately interpreting IVIg-dependency are discussed. Finally, the merit of subcutaneous IgG, the ineffectiveness of IVIg in IgG4-neurological autoimmunities, and genetic factors affecting IVIg dosing and efficacy are addressed.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, Dept. of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| |
Collapse
|
9
|
Schwotzer N, Paganetti G, Barchi M, Perrottet N, Aubert V, Sadallah S, Rotman S, Venetz JP, Matter M, Golshayan D, Pascual M. Upfront use of eculizumab to treat early acute antibody-mediated rejection after kidney allotransplantation and relevance for xenotransplantation. Xenotransplantation 2020; 27:e12630. [PMID: 32698246 DOI: 10.1111/xen.12630] [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] [Received: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 01/08/2023]
Abstract
Acute antibody-mediated rejection (AMR) early after transplant remains a challenge, both in allotransplantation and in xenotransplantation. We report the case of an early and severe acute AMR episode in a kidney transplant recipient that was successfully treated with upfront eculizumab. A 58-year-old woman had been on dialysis since 2014. She underwent a first kidney transplant in 2018 with primary non-function and received several blood transfusions. Postoperatively, she developed anti-HLA antibodies. One year later, she received a second allograft from a deceased donor. At day 0, there was only one preformed low-level donor-specific antibody (DSA) anti-DQ7. After initial excellent allograft function, serum creatinine increased on days 7-9, and this was associated with oligo-anuria. On day 7, there was an increase in her DSA anti-DQ7 and 4 de novo DSA had developed at high MFI values. Allograft biopsy showed severe active AMR with diffuse C4d deposits in peritubular capillaries. The early acute AMR episode was treated with upfront eculizumab administration (2 doses) with efficient CH50 blockade (< 10% CH50). Rituximab was also administered on day 12, and intravenous immunoglobulin (IVIG) was given over the following days. There was an excellent clinical response to eculizumab administration. Eculizumab administration rapidly reversed the acute AMR episode without the need for plasmapheresis. Rituximab and IVIG were also used as B-cell immunomodulators to decrease DSA. Blocking efficiently the terminal complement pathway may become a useful strategy to treat acute AMR in sensitized recipients of allografts, and possibly in recipients of discordant xenografts.
Collapse
Affiliation(s)
- Nora Schwotzer
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Giulia Paganetti
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Matteo Barchi
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Nancy Perrottet
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Salima Sadallah
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Samuel Rotman
- Service of clinical Pathology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Jean-Pierre Venetz
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Maurice Matter
- Visceral Surgery Department, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Dela Golshayan
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
10
|
Abstract
Therapeutic preparations of pooled normal polyspecific immunoglobulin G for intravenous use (intravenous immunoglobulin, IVIG) have been shown to be effective in the treatment of a number of autoimmune and systemic inflammatory conditions. IVIG prevents the occurrence of experimental autoimmune encephalomyelitis. Increasing evidence suggests that IVIG is of benefit in patients with relapsing-remitting multiple sclerosis. The present review discusses the immunoregulatory properties and mechanisms of action of IVIG in autoimmune disease.
Collapse
Affiliation(s)
- Michel D Kazatchkine
- INSERM U430 and Université Pierre et Marie Curie, Hôpital Broussais, 96 rue Didot, F-75014 Paris, France
| | - Blanche Bellon
- INSERM U430 and Université Pierre et Marie Curie, Hôpital Broussais, 96 rue Didot, F-75014 Paris, France
| | - Srini V Kaveri
- INSERM U430 and Université Pierre et Marie Curie, Hôpital Broussais, 96 rue Didot, F-75014 Paris, France
| |
Collapse
|
11
|
Mouthon L, Kaveri SV, Spalter SH, Lacroix-Desmazes S, Lefranc C, Desai R, Kazatchkine MD. Mechanisms of action of intravenous immune globulin in immune-mediated diseases. Clin Exp Immunol 2019. [DOI: 10.1111/cei.1996.104.s1.3] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
12
|
Gelfand EW, Landwehr LP, Esterl B, Mazer B. Intravenous immune globulin: an alternative therapy in steroid-dependent allergic diseases. Clin Exp Immunol 2019. [DOI: 10.1111/cei.1996.104.s1.61] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
13
|
Brem MD, Jacobs BC, van Rijs W, Fokkink WJR, Tio-Gillen AP, Walgaard C, van Doorn PA, IJspeert H, van der Burg M, Huizinga R. IVIg-induced plasmablasts in patients with Guillain-Barré syndrome. Ann Clin Transl Neurol 2018; 6:129-143. [PMID: 30656191 PMCID: PMC6331722 DOI: 10.1002/acn3.687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 01/08/2023] Open
Abstract
Objective The Guillain-Barré syndrome (GBS) is an acute, immune-mediated disease of peripheral nerves. Plasmablasts and plasma cells play a central role in GBS by producing neurotoxic antibodies. The standard treatment for GBS is high-dose intravenous immunoglobulins (IVIg), however the working mechanism is unknown and the response to treatment is highly variable. We aimed to determine whether IVIg changes the frequency of B-cell subsets in patients with GBS. Methods Peripheral blood mononuclear cells were isolated from 67 patients with GBS before and/or 1, 2, 4, and 12 weeks after treatment with high-dose IVIg. B-cell subset frequencies were determined by flow cytometry and related to serum immunoglobulin levels. Immunoglobulin transcripts before and after IVIg treatment were examined by next-generation sequencing. Antiglycolipid antibodies were determined by ELISA. Results Patients treated with IVIg demonstrated a strong increase in plasmablasts, which peaked 1 week after treatment. Flow cytometry identified a relative increase in IgG2 plasmablasts posttreatment. Within IGG sequences, dominant clones were identified which were also IGG2 and had different immunoglobulin sequences compared to pretreatment samples. High plasmablast frequencies after treatment correlated with an increase in serum IgG and IgM, suggesting endogenous production. Patients with a high number of plasmablasts started to improve earlier (P = 0.015) and were treated with a higher dose of IVIg. Interpretation High-dose IVIg treatment alters the distribution of B-cell subsets in the peripheral blood of GBS patients, suggesting de novo (oligo-)clonal B-cell activation. Very high numbers of plasmablasts after IVIg therapy may be a potential biomarker for fast clinical recovery.
Collapse
Affiliation(s)
- Maarten D Brem
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Bart C Jacobs
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands.,Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Wouter van Rijs
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands.,Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Willem Jan R Fokkink
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands.,Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Anne P Tio-Gillen
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands.,Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Christa Walgaard
- Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Pieter A van Doorn
- Department of Neurology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Hanna IJspeert
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Mirjam van der Burg
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| | - Ruth Huizinga
- Department of Immunology Erasmus MC University Medical Center Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands
| |
Collapse
|
14
|
Ahmed AR, Kaveri S. Reversing Autoimmunity Combination of Rituximab and Intravenous Immunoglobulin. Front Immunol 2018; 9:1189. [PMID: 30072982 PMCID: PMC6058053 DOI: 10.3389/fimmu.2018.01189] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/14/2018] [Indexed: 12/14/2022] Open
Abstract
In this concept paper, the authors present a unique and novel protocol to treat autoimmune diseases that may have the potential to reverse autoimmunity. It uses a combination of B cell depletion therapy (BDT), specifically rituximab (RTX) and intravenous immunoglobulin (IVIg), based on a specifically designed protocol (Ahmed Protocol). Twelve infusions of RTX are given in 6–14 months. Once the CD20+ B cells are depleted from the peripheral blood, IVIg is given monthly until B cells repopulation occurs. Six additional cycles are given to end the protocol. During the stages of B cell depletion, repopulation and after clinical recovery, IVIg is continued. Along with clinical recovery, significant reduction and eventual disappearance of pathogenic autoantibody occurs. Administration of IVIg in the post-clinical period is a crucial part of this protocol. This combination reduces and may eventually significantly eliminates inflammation in the microenvironment and facilitates restoring immune balance. Consequently, the process of autoimmunity and the phenomenon that lead to autoimmune disease are arrested, and a sustained and prolonged disease and drug-free remission is achieved. Data from seven published studies, in which this combination protocol was used, are presented. It is known that BDT does not affect check points. IVIg has functions that mimic checkpoints. Hence, when inflammation is reduced and the microenvironment is favorable, IVIg may restore tolerance. The authors provide relevant information, molecular mechanism of action of BDT, IVIg, autoimmunity, and autoimmune diseases. The focus of the manuscript is providing an explanation, using the current literature, to demonstrate possible pathways, used by the combination of BDT and IVIg in providing sustained, long-term, drug-free remissions of autoimmune diseases, and thus reversing autoimmunity, albeit for the duration of the observation.
Collapse
Affiliation(s)
- A Razzaque Ahmed
- Department of Dermatology, Tufts University School of Medicine, Boston, MA, United States.,Center for Blistering Diseases, Boston, MA, United States
| | - Srinivas Kaveri
- INSERM U1138 Centre de Recherche des Cordeliers, Paris, France
| |
Collapse
|
15
|
Montgomery RA, Loupy A, Segev DL. Antibody-mediated rejection: New approaches in prevention and management. Am J Transplant 2018; 18 Suppl 3:3-17. [PMID: 29292861 DOI: 10.1111/ajt.14584] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/26/2017] [Accepted: 11/04/2017] [Indexed: 01/25/2023]
Abstract
Despite the success of desensitization protocols, antibody-mediated rejection (AMR) remains a significant contributor to renal allograft failure in patients with donor-specific antibodies. Plasmapheresis and high-dose intravenous immunoglobulin have proved to be effective treatments to prevent and treat AMR, but irreversible injury in the form of transplant glomerulopathy can commonly manifest months to years later. There is an unmet need to improve the outcomes for patients at risk for AMR. Updated Banff criteria now take into account the increasing understanding of the complex and heterogeneous nature of AMR phenotypes, including the timing of rejection, subclinical and chronic AMR, C4d-negative AMR, and antibody-mediated vascular rejection. Treatment for AMR is not standardized, and there is little in the way of evidence-based treatment guidelines. Refining more precisely the mechanisms of injury responsible for different AMR phenotypes and establishing relevant surrogate endpoints to facilitate more informative studies will likely allow for more accurate determination of prognosis and efficacious intervention using new therapeutic approaches. In addition to plasma exchange and intravenous immunoglobulin, a number of other add-on therapies have been tried in small studies without consistent benefit, including anti-CD20, proteasome inhibitors, complement inhibitors, anti-interleukin-6 receptor blockers, and immunoglobulin G-degrading enzyme of Streptococcus pyogenes (called IdeS).
Collapse
Affiliation(s)
- R A Montgomery
- Department of Surgery and NYU Langone Transplant Institute, NYU Langone Medical Center, New York, NY, USA
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and Kidney Transplantation, Hôpital Necker, INSERM U 970, Paris Descartes University, Paris, France
| | - D L Segev
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
16
|
First line treatment of pemphigus vulgaris with a novel protocol in patients with contraindications to systemic corticosteroids and immunosuppressive agents: Preliminary retrospective study with a seven year follow-up. Int Immunopharmacol 2016; 34:25-31. [DOI: 10.1016/j.intimp.2016.02.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 11/15/2022]
|
17
|
Intravenous Immunoglobulins: Mode of Action and Indications in Autoimmune and Inflammatory Dermatoses. Int J Inflam 2016; 2016:3523057. [PMID: 26885437 PMCID: PMC4739470 DOI: 10.1155/2016/3523057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/21/2015] [Indexed: 11/18/2022] Open
Abstract
Intravenous immunoglobulins (IVIGs), a mixture of variable amounts of proteins (albumin, IgG, IgM, IgA, and IgE antibodies), as well as salt, sugar, solvents, and detergents, are successfully used to treat a variety of dermatological disorders. For decades, IVIGs have been administered for treatment of infectious diseases and immune deficiencies, since they contain natural antibodies that represent a first-line defense against pathogens. Today their indication has expanded, including the off-label therapy for a variety of autoimmune and inflammatory diseases. In dermatology, IVIGs are administered for treatment of different disorders at different therapeutic regimens, mostly with higher doses then those administered for treatment of infectious diseases. The aim of this prospective review is to highlight the indications, effectiveness, side effects, and perspectives of the systemic treatment with IVIGs for patients with severe, life-threatening, and resistant to conventional therapies autoimmune or inflammatory dermatoses.
Collapse
|
18
|
Bembeeva RT, Zavadenko NN. [Intravenous immunoglobulin in treatment of autoimmune neurological diseases in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:83-93. [PMID: 26356621 DOI: 10.17116/jnevro20151156183-93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Though the mechanisms of action of intravenous immunoglobulins (IVIG) are not completely understood, these drugs are widely used in treatment of autoimmune diseases. In this review, we have analyzed the literature on the use of IVIG in the treatment of autoimmune diseases of the nervous system in children and discuss the management of patients basing on the recommendation of the European Federation of Neurological Societies. The efficacy of IVIG in children has been shown as first line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, dermatomyositis as a second-line drug in the combination with prednisolone or immunosuppressors in patients refractory to treatment with corticosteroids and cytostatics, myasthenic crisis in myasthenia gravis, exacerbations and short-term treatment of severe forms, non-responsiveness to acetylcholinesterase inhibitors, multiple sclerosis as second or third line of treatment in patients with relapsing-remitting course with intolerance to standard immunomodulatory therapy, acute multiple encephalomyelitis with no response to the treatment with high doses of corticosteroids, paraneoplastic syndromes, pharmacoresistant epilepsy and autoimmune encephalitis. Because the right choice of the drug plays a key role, in particular, in children, that determines the efficacy and safety of the treatment, we present the main approaches to the choice of the drug and schemes of treatment of autoimmune diseases of the nervous system in children.
Collapse
Affiliation(s)
- R Ts Bembeeva
- Pirogov Russian National Research Medical University, Moscow
| | - N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow
| |
Collapse
|
19
|
Kaveri SV, Lecerf M, Saha C, Kazatchkine MD, Lacroix-Desmazes S, Bayry J. Intravenous immunoglobulin and immune response. Clin Exp Immunol 2015; 178 Suppl 1:94-6. [PMID: 25546777 DOI: 10.1111/cei.12526] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- S V Kaveri
- Unité 1138, Institut National de la Santé et de la Recherche Médicale, UPMC Univ Paris 06, UMR_S 1138, Paris, France; Centre de Recherche des Cordeliers, Equipe-Immunopathology and Therapeutic Immunointervention, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Paris, France
| | | | | | | | | | | |
Collapse
|
20
|
Intravenous immunoglobulin treatment in chronic neurological diseases: do we have maintenance dose right? Autoimmune Dis 2014; 2014:962530. [PMID: 25580286 PMCID: PMC4281444 DOI: 10.1155/2014/962530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/30/2014] [Indexed: 11/21/2022] Open
Abstract
Objectives. We tried to define, on individual basis, minimal effective maintenance dose of intravenous immunoglobulins (IVIG) in 26 patients with chronic neurological conditions requiring long-term IVIG treatment. Methods. Clinical criteria were reviewed in individual cases (Phase 1) followed by titration phase (Phase 2, 12 months) and posttitration/follow-up phase (Phase 3, 3 months). Objective neurological examination and patient self-reports were used for clinical follow-up. Results. 69.2% of patients reported condition as stable, 26.9% as better, and 3.9% as mildly worse. Original mean monthly dose was 1 g/kg; over the period of 12 months we reduced dose of IVIG to mean dose 0.67 g/kg (range 0.3–2.5 g/kg, P < 0.0001) which meant reduction by 36.4%. We identified 4 nonresponders and diagnosis in one case was reclassified to degenerative disease. In follow-up phase we reduced dose further to 0.60 g/kg. Cumulative monthly dose dropped from 2040 g to 1298 g and to 991 g, respectively. Financial expenses were reduced significantly (by −36.4% during titration phase and by −51.4% during follow-up phase) (comparing with baseline) (P < 0.0001). Conclusion. Individual dose titration leads to significant maintenance IVIG dose reduction with preserved clinical efficacy. Maintenance dose below 1 g/kg (in our study around 0.7 g/kg) has acceptable risk/benefit ratio.
Collapse
|
21
|
Loeffler DA, Klaver AC, Coffey MP. Aβanti-idiotypic antibodies are present in intravenous immunoglobulin and are produced in mice following its administration. Autoimmunity 2014; 48:196-200. [DOI: 10.3109/08916934.2014.983265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
22
|
Dalakas MC. Mechanistic effects of IVIg in neuroinflammatory diseases: conclusions based on clinicopathologic correlations. J Clin Immunol 2014; 34 Suppl 1:S120-6. [PMID: 24722854 DOI: 10.1007/s10875-014-0024-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/19/2014] [Indexed: 12/29/2022]
Abstract
The mechanisms of action of IVIg on immunoregulatory and neuroinflammatory network have been predominantly based on in vitro experiments and animal studies, rather than direct effects on human tissues. Based on clinicopathologic correlations and tissues obtained before and after IVIg therapy, the better documented and clinically-relevant in-vivo actions of IVIg include effects on: a) Antibodies. An extracted antigen-specific anti-immunoglobulin (idiotypic) fraction appears partially responsible for its effect in myasthenia gravis and GBS; b) Complement. Sera from Dermatomyositis (DM) patients responding to IVIg, inhibit complement consumption and intercept MAC formation leading to disappearance of MAC deposits in the repeated muscle biopsies and normalization of muscle tissue; c) Genes. In repeated muscle biopsies from DM patients who improved after IVIg, but not from Inclusion-Body-Myositis (IBM) who did not improve, there is a 2-fold alteration of 2206 tissue genes associated with inflammation, fibrosis, tissue remodeling and regeneration; and d) degenerative-proinflammatory molecules and β-amyloid, implicated in neurodegenerative CNS diseases and IBM. In repeated muscle biopsies of IBM patients who did not respond to IVIg, the mRNA or protein expression for chemokines, IFN-γ, TGF-ß, IL-10, Ubiquitin and aB-crystallin is reduced, but not for the key molecules ICOS, ICOSL, IL-6, IL1-β, perforin, APP, nitric oxide synthase and nitrotyrosine, in spite of good IVIg penetration in muscles. Collectively, the selective effectiveness of IVIg in human diseases seems to correlate in vivo with inhibition of causative inflammatory mediators. Study of accessible tissues before and after therapy and clinicopathologic correlations, may help explain the differential effect of IVIg in autoimmune or neuroinflammatory diseases.
Collapse
|
23
|
|
24
|
Affiliation(s)
- Erwin W Gelfand
- Division of Cell Biology, Department of Pediatrics, National Jewish Health, Denver, CO 80206, UDA.
| |
Collapse
|
25
|
Affiliation(s)
- E Richard Stiehm
- Division of Immunology/Allergy/Rheumatology, Mattel Children's Hospital, UCLA School of Medicine at UCLA, CA, USA.
| | | | | | | |
Collapse
|
26
|
Néron S, Boire G, Dussault N, Racine C, de Brum-Fernandes AJ, Côté S, Jacques A. CD40-activated B cells from patients with systemic lupus erythematosus can be modulated by therapeutic immunoglobulins in vitro. Arch Immunol Ther Exp (Warsz) 2009; 57:447-58. [DOI: 10.1007/s00005-009-0048-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 04/29/2009] [Indexed: 01/19/2023]
|
27
|
Imbach P, Lazarus AH, Kühne T. Intravenous immunoglobulins induce potentially synergistic immunomodulations in autoimmune disorders. Vox Sang 2009; 98:385-94. [PMID: 19821958 DOI: 10.1111/j.1423-0410.2009.01264.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The increase in platelets in patients with immune thrombocytopenia (ITP) by intravenous administration of human immunoglobulin concentrates (IVIG) reflects a therapeutic immunomodulatory intervention targeted at the disturbed immune response in many inflammatory and autoimmune disorders. These immunoglobulin concentrates contain large numbers of antibodies as well as trace levels of various other immunologically active molecules. Clinical and laboratory studies have documented various mechanisms of action of IVIG. The complex network of immunological reactions resulting from the infusion of IVIG includes changes in several cytokines, interactions with dendritic cells, T- and B- lymphocyte effects, macrophage effects, mediated by distinct Fc-gamma receptors. In addition, effects on complement components and apoptosis have also been observed. Synergism between the different elements of the immune response characterizes the beneficial effects of IVIG in inflammatory and autoimmune disorders. They have immunopathogeneses and clinical manifestations which are difficult to define and therefore IVIG treatment indications remain heterogeneous. Dose finding studies are missing for most of the indications of the drug. In future research, defining the appropriate subgroups of patients should be undertaken. This may be accomplished by prospective registries collecting data on large numbers of patients with long-term follow-up. Controlled clinical and laboratory studies may follow based on new, validated patient selection criteria and focused on mechanisms of action, leading to more evidence-based indications.
Collapse
Affiliation(s)
- P Imbach
- Pediatric Hematology-Oncology, University Children's Hospital, Medical Faculty of University of Basel, Basel, Switzerland.
| | | | | |
Collapse
|
28
|
Dussault N, Ducas E, Racine C, Jacques A, Paré I, Côté S, Néron S. Immunomodulation of human B cells following treatment with intravenous immunoglobulins involves increased phosphorylation of extracellular signal-regulated kinases 1 and 2. Int Immunol 2008; 20:1369-79. [PMID: 18689724 DOI: 10.1093/intimm/dxn090] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
In the treatment of autoimmune diseases, intravenous Igs (IVIg) are assumed to modulate immune cells through the binding of surface receptors. IVIg act upon definite human B cell populations to modulate Ig repertoire, and such modulation might proceed through intracellular signaling. However, the heterogeneity of human B cell populations complicates investigations of the intracellular pathways involved in IVIg-induced B cell modulation. The aim of this study was to establish a model allowing the screening of IVIg signal transduction in human B cell lines and to attempt transposing observations made in cell lines to normal human B lymphocytes. Nine human B cell lines were treated with IVIg with the goal of selecting the most suitable model for human B lymphocytes. The IgG(+) DB cell line, whose response was similar to that of human B lymphocytes, showed reduced IVIg modulation following addition of PD98059, an inhibitor of extracellular signal-regulated protein kinase 1/2 (ERK1/2). The IVIg-induced ERK1/2 phosphorylation was indeed proportional to the dosage of monomeric IVIg used when tested on DB cells as well as Pfeiffer cells, another IgG(+) cell line. In addition, two other intermediates, Grb2-associated binder 1 (Gab1) and Akt, showed increased phosphorylation in IVIg-treated DB cells. IVIg induction of ERK1/2 phosphorylation was finally observed in peripheral human B lymphocytes, specifically within the IgG(+) B cell population. In conclusion, IVIg immunomodulation of human B cells can thus be linked to intracellular transduction pathways involving the phosphorylation of ERK1/2, which in combination with Gab1 and Akt, may be related to B cell antigen receptor signaling.
Collapse
Affiliation(s)
- Nathalie Dussault
- Héma-Québec, Ingénierie cellulaire, Recherche et développement, Sainte-Foy, Québec, Canada
| | | | | | | | | | | | | |
Collapse
|
29
|
Wan EC, Gordon TP, Jackson MW. Autoantibodies to calcium channels in type 1 diabetes mediate autonomic dysfunction by different mechanisms in colon and bladder and are neutralized by antiidiotypic antibodies. J Autoimmun 2008; 31:66-72. [PMID: 18472396 DOI: 10.1016/j.jaut.2008.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 03/18/2008] [Accepted: 03/18/2008] [Indexed: 12/27/2022]
Abstract
Autoantibodies (Abs) directed against L-type voltage-gated calcium channels (VGCCs) have been shown to contribute to autonomic dysfunction of the gastrointestinal tract and bladder in patients with Type 1 diabetes mellitus (T1D). We used a passive transfer model to determine whether the functional activity of the Ab requires crosslinking of channels in colon and bladder and can be neutralized by intravenous immunoglobulin (IVIg). Mice were injected with mono- and divalent F(ab) fragments of patient IgG with anti-VGCC activity and tested for gut and bladder function using a colonic migrating motor complex (MMC) assay and bladder-filling cystometry. The ability of IVIg to neutralize anti-VGCC IgG-mediated autonomic dysfunction was investigated by injection of mice with an equimolar concentration of IVIg prior to T1D IgG injection, or by injection with T1D IgG passed over a sepharose 4B column coupled with F(ab')(2) from IVIg. Passive transfer of T1D IgG and its F(ab')(2) or F(ab) fragments reduced the amplitude of spontaneous colonic motility. In contrast, intact IgG and F(ab')(2,) but not F(ab), produced the urodynamics features of an overactive bladder. T1D IgG-mediated colonic and bladder dysfunction was neutralized in vivo by prior injection of animals with equimolar IVIg. Moreover, anti-VGCC activity was depleted by preabsorption of patient IgG on a IVIg F(ab')(2) column. The activity of anti-VGCC IgG is mediated by the antigen-binding site consistent with a true functional Ab. The pathogenic effect on the bladder requires crosslinking of the channel, whereas monovalent binding of Ab is sufficient for disruption of colon motility. The anti-VGCC Abs are neutralized by antiidiotypic antibodies present in IVIg that may prevent the emergence of these Abs in healthy individuals.
Collapse
Affiliation(s)
- En-Chi Wan
- Department of Immunology, Allergy and Arthritis, Flinders Medical Centre and Flinders University, Bedford Park, Adelaide, South Australia 5042, Australia
| | | | | |
Collapse
|
30
|
Abstract
The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.
Collapse
Affiliation(s)
- Anthony P Fernandez
- Department of Dermatology and Cutaneous Surgery, Unversity of Miami Miller School of Medicine, Miami, Florida, USA
| | | |
Collapse
|
31
|
Sibéril S, Elluru S, Graff-Dubois S, Negi VS, Delignat S, Mouthon L, Lacroix-Desmazes S, Kazatchkine MD, Bayry J, Bayary J, Kaveri SV. Intravenous Immunoglobulins in Autoimmune and Inflammatory Diseases: A Mechanistic Perspective. Ann N Y Acad Sci 2007; 1110:497-506. [PMID: 17911465 DOI: 10.1196/annals.1423.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Initially used for the treatment of immunodeficiencies, intravenous immunoglobulins (IVIg) have increasingly been used as immunomodulatory agents in autoimmune and inflammatory disorders. The mode of action of IVIg is enigmatic, probably involving Fc-dependent and/or F(ab')2-dependent nonexclusive mechanisms of action. IVIg broadly interacts with the different components of the immune system: cytokines, complement, Fc receptors, and several cell surface immunocompetent molecules. IVIg has also an impact on effector functions of immune cells. These mechanisms of action of IVIg reflect the importance of natural antibodies in the maintenance of immune homeostasis. We discuss here the recent advances in the understanding of immunoregulatory effects of IVIg, and we pointed out the need for new strategies to overcome the predicted increasing worldwide shortage of IVIg.
Collapse
Affiliation(s)
- Sophie Sibéril
- INSERM UMRS 872, Université René Descartes (Paris-5), Université Pierre et Marie Curie (UPMC Paris-6) 75006 Paris, France
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Sibéril S, Elluru S, Negi VS, Ephrem A, Misra N, Delignat S, Bayary J, Lacroix-Desmazes S, Kazatchkine MD, Kaveri SV. Intravenous immunoglobulin in autoimmune and inflammatory diseases: More than mere transfer of antibodies. Transfus Apher Sci 2007; 37:103-7. [PMID: 17765663 DOI: 10.1016/j.transci.2007.01.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 01/07/2007] [Indexed: 01/21/2023]
Abstract
Initially used for the treatment of immunodeficiencies, intravenous immunoglobulin (IVIg) has increasingly been used as an immunomodulatory agent in immune thrombocytopenic purpura, autoimmune neuropathies, systemic lupus erythematosus, myasthenia gravis, Guillain-Barré syndrome, and Kawasaki disease. Although IVIg benefits have been reported in many autoimmune and systemic inflammatory diseases, its mechanisms of immunomodulation are not fully understood and probably involve Fc-dependent and/or F(ab')(2)-dependent mutually non-exclusive effects. These mechanisms of action of IVIg reflect the importance of natural antibodies in the maintenance of immune homeostasis. We discuss here the recent advances in the understanding of immunoregulatory effects of IVIg.
Collapse
Affiliation(s)
- Sophie Sibéril
- Centre de Recherche des Cordeliers, Equipe 16- Immunopathology and therapeutic immunointervention, Université Pierre et Marie Curie Paris 6, UMR S 872, 15 rue de l'Ecole de Médicine, Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Graff-Dubois S, Sibéril S, Elluru S, Negi VS, Delignat S, Mouthon L, Lacroix-Desmazes S, Kazatchkine MD, Bayary J, Kaveri SV. Utilisation des immunoglobulines polyclonales intraveineuses dans les pathologies auto-immunes et inflammatoires. Transfus Clin Biol 2007; 14:63-8. [PMID: 17498995 DOI: 10.1016/j.tracli.2007.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Initially used for the treatment of immunodeficiencies, intravenous immunoglobulins (IVIg) have increasingly been used as immunomodulatory agent in autoimmune and inflammatory disorders. The mode of action of IVIg is enigmatic, probably involving Fc-dependent and/or F(ab')2-dependent non-exclusive mechanisms of action. IVIg broadly interacts with the different components of the immune system: cytokines, complement, Fc receptors and several cell surface immunocompetent molecules. IVIg also has an impact on effector functions of immune cells. These mechanisms of action of IVIg reflect the importance of natural antibodies in the maintenance of immune homeostasis. We discuss here the recent advances in the understanding of immunoregulatory effects of IVIg, and we pointed out the need of new strategies to overcome the predicted increasing worldwide shortage of IVIg.
Collapse
Affiliation(s)
- Stéphanie Graff-Dubois
- INSERM U 872, université René-Descartes (Paris-5), université Pierre-et-Marie-Curie (UPMC Paris-6) et équipe 16 (immunopathologie et immunointervention thérapeutique), centre de recherche des Cordeliers, 15 rue de l'Ecole-de-Médecine, 75006 Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Negi VS, Elluru S, Sibéril S, Graff-Dubois S, Mouthon L, Kazatchkine MD, Lacroix-Desmazes S, Bayry J, Kaveri SV. Intravenous immunoglobulin: an update on the clinical use and mechanisms of action. J Clin Immunol 2007; 27:233-45. [PMID: 17351760 DOI: 10.1007/s10875-007-9088-9] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 02/21/2007] [Indexed: 01/27/2023]
Abstract
Initially used as a replacement therapy for immunodeficiency diseases, intravenous immunoglobulin (IVIg) is now widely used for a number of autoimmune and inflammatory diseases. Considerable progress has been made in understanding the mechanisms by which IVIg exerts immunomodulatory effects in autoimmune and inflammatory disorders. The mechanisms of action of IVIg are complex, involving modulation of expression and function of Fc receptors, interference with activation of complement and the cytokine network and of idiotype network, regulation of cell growth, and effects on the activation, differentiation, and effector functions of dendritic cells, and T and B cells.
Collapse
Affiliation(s)
- Vir-Singh Negi
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Soo Hoo W, Jensen ER, Saadat A, Nieto D, Moss RB, Carlo DJ, Moll T. Vaccination with cell immunoglobulin mucin-1 antibodies and inactivated influenza enhances vaccine-specific lymphocyte proliferation, interferon-gamma production and cross-strain reactivity. Clin Exp Immunol 2006; 145:123-9. [PMID: 16792682 PMCID: PMC1941996 DOI: 10.1111/j.1365-2249.2006.03107.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Influenza virus causes a contagious and potentially serious infection of the upper respiratory tract. While neutralizing antibodies are protective against infection, the problem of antigenic drift remains, requiring the constant monitoring and development of new vaccines. The magnitude of this situation is underscored by the emergence of new potentially human pathogenic influenza strains, avian H5N1 being the most recent example. We present evidence that antibodies against T cell immunoglobulin mucin-1 (TIM-1), a recently identified immunomodulatory molecule, stimulate cellular immunity against influenza viruses and cross-strain immune reactivity. To determine potential immunostimulatory properties of anti-TIM-1, mice were vaccinated with inactivated influenza virus in the presence or absence of TIM-1-specific monoclonal antibodies. Development of cellular immunity against both the influenza strain used for immunization and serotypically distinct virus strains was monitored 3 weeks after vaccination by determining antigen-specific lymphocyte proliferation and cytokine production. Results show that TIM-1 antibodies enhance antigen-specific cellular proliferation (P < 0.05) and interferon (IFN)-gamma production (P < 0.01). Using blocking anti-CD4 and CD8 antibodies, it was observed that antigen-specific cellular proliferation is CD4-dependent and that the majority of proliferating cells are CD4+. Finally, vaccination with inactivated influenza virus with TIM-1 antibody results in the significant (P < 0.001) induction of proliferation and IFN-gamma production upon stimulation with one of three serologically distinct strains. TIM-1 antibodies demonstrate an adjuvant effect promoting antigen-specific cellular proliferation and IFN-gamma production, which are important for the promotion of cell-mediated immunity. These results are the first to suggest that TIM-1 antibody may serve as a potent adjuvant in the development of new influenza virus vaccines.
Collapse
Affiliation(s)
- W Soo Hoo
- Telos Pharmaceuticals LLC, San Diego, CA 92131, USA.
| | | | | | | | | | | | | |
Collapse
|
36
|
Léonard S, Pierard I, Michaelsen TE, Izui S, Masson PL, Coutelier JP. Variability of the inhibition by total immunoglobulin of in vitro autoantibody-mediated erythrophagocytosis by mouse macrophages. Clin Exp Immunol 2006; 145:155-61. [PMID: 16792686 PMCID: PMC1941991 DOI: 10.1111/j.1365-2249.2006.03117.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Several autoimmune diseases, mainly autoantibody-mediated, are attenuated by infusion of total IgG (IVIg). The efficacy varies widely from one patient to another. Using an experimental model of in vitro phagocytosis of autoantibody-coated erythrocytes by mouse macrophages, we analysed the possible causes for such a variability. Our results indicated that the efficacy of the phagocytosis inhibition depends upon different factors, such as the isotype and the extent of polymerization of the immunoglobulin used for the treatment as well as the genetic background of the mice and the state of macrophage activation that can be influenced by concomitant viral infection. The development of an in vitro assay for the phagocytic activity of macrophages might improve the selection of patients susceptible to benefit from IVIg treatment.
Collapse
Affiliation(s)
- S Léonard
- Unit of Experimental Medicine, Christian de Duve Institute of Cellular Pathology, Université Catholique de Louvain, Bruxelles, Belgium
| | | | | | | | | | | |
Collapse
|
37
|
Kirschbaum J, Forschner K, Rasche C, Worm M. Modulation of lymphocyte phenotype and function by immunoglobulins. Br J Dermatol 2006; 154:225-30. [PMID: 16433789 DOI: 10.1111/j.1365-2133.2005.07005.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Immunoglobulins have immune-modulating capacities and are used for the treatment of different dermatological diseases. They have also been reported for the treatment of severe atopic dermatitis (AD). OBJECTIVES To determine the effects of immunoglobulins on the phenotype and function of peripheral T and B lymphocytes from patients with AD in comparison with healthy donors (HD) as controls. METHODS We studied lymphocyte activation and T-cell cytokine production from 12 patients with AD and 10 HD by multicolour flow cytometric analysis in the presence of immunoglobulins. RESULTS Immunoglobulins significantly inhibited T-cell activation (CD69), by 71% (AD) and by 62% (HD). Production of interferon-gamma and interleukin-4 was also significantly inhibited, by 44%/24% (AD) and 38%/10% (HD), respectively. In addition, CD86 expression on B lymphocytes was downregulated by 30% in AD and by 29% in HD, whereas CD23 expression was decreased without reaching statistical significance. CONCLUSIONS Our data demonstrate that, in vitro, immunoglobulins modulate the activation and cytokine production of peripheral blood lymphocytes from both HD and patients with AD.
Collapse
Affiliation(s)
- J Kirschbaum
- Allergy-Center-Charité, Department of Dermatology and Allergy, Charité-Universitàtsmedizin Berlin, Schumannstr, 20-21, 10117 Berlin, Germany
| | | | | | | |
Collapse
|
38
|
Bayry J, Bayary J, Dasgupta S, Misra N, Ephrem A, Duong Van Huyen JP, Delignat S, Hassan G, Caligiuri G, Nicoletti A, Lacroix-Desmazes S, Kazatchkine MD, Kaveri S. Intravenous immunoglobulin in autoimmune disorders: An insight into the immunoregulatory mechanisms. Int Immunopharmacol 2006; 6:528-34. [PMID: 16504915 DOI: 10.1016/j.intimp.2005.11.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intravenous immunoglobulin (IGIV) has increasingly been used for the treatment of autoimmune and systemic inflammatory diseases in addition to supportive therapy of immunodeficient patients. IGIV is beneficial in several diseases, including acute and chronic/relapsing diseases, autoimmune diseases and inflammatory disorders. Therapeutic efficacy of IGIV has also been established in a number of dermatologic diseases. Although a considerable progress has been made in understanding the mechanisms by which IGIV exerts immunomodulatory functions in autoimmune diseases, they remain not fully elucidated. The mode of action of IGIV is complex, involving modulation of expression and function of Fc receptors, interference with activation of complement and the cytokine network, modulation of idiotype network, regulation of cell growth, alteration of cellular adhesion process, and effects on the activation differentiation and effector functions of T and B cells and of antigen-presenting cells. The therapeutic effects of IGIV most likely reflect the functions of natural antibodies in maintaining immune homeostasis in healthy people. The ability of IGIV to interact through V regions with complementary V regions of antibodies and antigen receptors as well as with relevant soluble and surface molecules provides the basis for inducing the selection of immune repertoires. Since IGIV is frequently used to treat autoimmune and inflammatory diseases for which evidence of its efficacy is insufficiently documented, controlled trials, particularly of some neurologic and dermatologic diseases, are imperative.
Collapse
Affiliation(s)
- Jagadeesh Bayry
- INSERM, U681, Université Pierre et Marie Curie (UPMC-Paris 6), France
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Boros P, Gondolesi G, Bromberg JS. High dose intravenous immunoglobulin treatment: mechanisms of action. Liver Transpl 2005; 11:1469-80. [PMID: 16315304 DOI: 10.1002/lt.20594] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intravenous immunoglobulin (IVIg) treatment was introduced as replacement therapy for patients with antibody deficiencies, but evidence suggests that a wide range of immune-mediated conditions could benefit from IVIg. The immunoglobulins are precipitated from human plasma by fractionation methods. In conclusion, the differences in basic fractionation methods and the addition of various modifications for purification, stabilization, and virus inactivation result in products significantly different from each other.
Collapse
Affiliation(s)
- Peter Boros
- Recanati/Miller Transplantation Institute, The Mount Sinai School of Medicine, PO Box 1504, New York, NY 10029-6574, USA.
| | | | | |
Collapse
|
40
|
Abstract
KEY POINTS Intravenous immunoglobulins (IVIg) are preparations of normal human IgG obtained from large pools of healthy blood donors. IVIg can be used at low doses to treat patients with primary or secondary immune deficiencies and at high doses as an immunomodulatory agent in many autoimmune and systemic inflammatory diseases, especially hematologic and neurologic diseases. Its mechanisms of action are multiple, complex, and not yet well elucidated. Adverse effects are only rarely associated with IVIg. They are well tolerated, and the risk of transmission of infectious agents appears only theoretical.
Collapse
Affiliation(s)
- L Mouthon
- Université Paris-Descartes, Groupe hospitalier Cochin-Saint Vincent-de-Paul, Service de médecine interne, Centre de référence vascularites et sclérodermies, AP-HP, 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14(75), France.
| | | | | | | |
Collapse
|
41
|
Lemieux R, Bazin R, Néron S. Therapeutic intravenous immunoglobulins. Mol Immunol 2005; 42:839-48. [PMID: 15829272 DOI: 10.1016/j.molimm.2004.07.046] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Accepted: 07/13/2004] [Indexed: 01/24/2023]
Abstract
Intravenous immunoglobulins (IVIg) are concentrated formulations of human IgG prepared by industrial fractionation of large pools of individual plasma donations. IVIg were developed 20 years ago for the prophylaxis support of immunodeficient patients. However, IVIg have been increasingly used since 10 years, in the treatment of many autoimmune and inflammatory diseases raising the possibility of product shortages and ever increasing costs in the near future. Surprisingly, the immunomodulatory mechanisms of action of IVIg are unclear because of the diversity and often contradictory Fc, F(ab')(2), and non-IgG-related mechanisms that have been proposed from clinical observations and from results obtained in various in vitro and in vivo experimental models. These concepts are reviewed here and we discuss in more details three areas of active research, namely the mechanisms of IVIg action in Idiopathic Thrombocytopenic Purpura (ITP), the effects of IVIg on activated B lymphocytes and the possible involvement of autoantibodies of IgG isotype (auto-IgG) in the immunomodulatory effects of IVIg. The elucidation of the mechanisms of action of IVIg is crucial for a more rationalized clinical use of IVIg and for developing substitutes for some of the immunomodulatory indications in order to ensure long-term availability of plasma-derived IVIg for immunodeficient patients.
Collapse
Affiliation(s)
- Réal Lemieux
- HEMA-QUEBEC, Research and Development and Department of Biochemistry and Microbiology, Faculty of Sciences and Engineering, Laval University, Ste-Foy, Canada G1V 5C3.
| | | | | |
Collapse
|
42
|
Misra N, Bayry J, Ephrem A, Dasgupta S, Delignat S, Duong Van Huyen JP, Prost F, Lacroix-Desmazes S, Nicoletti A, Kazatchkine MD, Kaveri SV. Intravenous immunoglobulin in neurological disorders: a mechanistic perspective. J Neurol 2005; 252 Suppl 1:I1-6. [PMID: 15959666 DOI: 10.1007/s00415-005-1102-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intravenous immunoglobulin (IVIg) has been used in the treatment of primary and secondary antibody deficiencies for over 25 years. It is a safe preparation with no long-term side effects. IVIg was first demonstrated to be effective in autoimmune disorders, two decades ago, in the treatment of acute immune thrombocytopenia. Since then, the therapeutic efficacy of IVIg has been established in Guillain Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), myasthenia gravis (MG), dermatomyositis (DM), Kawasaki syndrome and the prevention of graft-versus-host disease in recipients of allogeneic bone marrow transplants and reported in a large number of other autoimmune and systemic inflammatory conditions.
Collapse
Affiliation(s)
- Namita Misra
- INSERM U681, Université Pierre et Marie Curie Institut des Cordeliers, 15 rue de l'Ecole de Médecine, Paris, France
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Djoumerska I, Tchorbanov A, Pashov A, Vassilev T. The Autoreactivity of Therapeutic Intravenous Immunoglobulin (IVIg) Preparations Depends on the Fractionation Methods Used. Scand J Immunol 2005; 61:357-63. [PMID: 15853919 DOI: 10.1111/j.1365-3083.2005.01568.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Natural immunoglobulin G (IgG) autoantibodies are present in the plasma of healthy individuals and, as a result, in pooled therapeutic intravenous immunoglobulin (IVIg) preparations. The production processes of commercial IVIg preparations involve different fractionation and virus-inactivation steps that include in some cases treatments at extreme conditions. Different physical and chemical treatments are known to augment greatly the reactivity of natural autoantibodies to self-antigens. It is not clear to what extent the self-reactivity of IVIg preparations is due to the presence of natural IgG antibodies in the plasma pools used for fractionation, and to what extent it is due to the treatments that the IgG molecules have been subjected to during the fractionation process. We compared the binding of seven different commercial IVIg preparations to human liver antigens. All studied IVIg's could be clearly separated into two distinct groups: those that possess significant self-reactivity and those with low binding to self-antigens. Increased self-binding was seen in the preparations produced using a fractionation step at low pH. The treatment of IVIg at low pH resulted in increasing the inhibitory effect of the pooled IgG on PHA-induced proliferation of human peripheral blood mononuclear cells. IVIg's with high and low self-binding may have different immunomodulating activities when infused to autoimmune patients.
Collapse
Affiliation(s)
- I Djoumerska
- Department of Immunology, Stefan Angelov Institute of Microbiology, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | | | | | | |
Collapse
|
44
|
Djoumerska IK, Tchorbanov AI, Donkova-Petrini VD, Pashov AD, Vassilev TL. Serum IgM, IgG and IgA block by F(ab')-dependent mechanism the binding of natural IgG autoantibodies from therapeutic immunoglobulin preparations to self-antigens. Eur J Haematol 2005; 74:101-10. [PMID: 15654899 DOI: 10.1111/j.1600-0609.2004.00350.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Natural polyreactive IgG autoantibodies are present in the plasma of healthy individuals and as a result in pooled therapeutic intravenous immunoglobulin (i.v.Ig) preparations. The spectrum of self-antigens to which these autoantibodies bind, their fate after intravenous infusion and their biological activity are not well understood. The identity of serum proteins that mask binding of natural autoantibodies to self-proteins is a matter of controversy. The spectrum of native serum proteins bound by i.v.Ig was analyzed by two-dimensional electrophoresis. The reactivity of i.v.Ig was directed mainly to circulating immunoglobulins. The binding of the IgG autoantibodies from i.v.Ig to native human liver antigens was blocked not only by a F(ab')2-dependent mechanism by circulating IgM and IgG (as has been previously suggested), but also by serum IgA. This control of anti-self reactivity may be inefficient in some autoimmune diseases.
Collapse
Affiliation(s)
- Iglika K Djoumerska
- Department of Immunology, Stefan Angelov Institute of Microbiology, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | | | | | | | | |
Collapse
|
45
|
Dalakas MC. The use of intravenous immunoglobulin in the treatment of autoimmune neuromuscular diseases: evidence-based indications and safety profile. Pharmacol Ther 2004; 102:177-93. [PMID: 15246245 DOI: 10.1016/j.pharmthera.2004.04.002] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Intravenous immunoglobulin (i.v.Ig) has multiple actions on the immunoregulatory network that operate in concert with each other. For each autoimmune neuromuscular disease, however, there is a predominant mechanism of action that relates to the underlying immunopathogenetic cause of the respective disorder. The best understood actions of i.v.Ig include the following: (a) modulation of pathogenic autoantibodies, an effect relevant in myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and stiff-person syndrome (SPS); (b) inhibition of complement activation and interception of membranolytic attack complex (MAC) formation, an action relevant to the complement-mediated mechanisms involved in GBS, CIDP, MG, and dermatomyositis (DM); (c) modulation of the inhibitory or activation Fc receptors on macrophages invading targeted tissues in nerve and muscle, as seen in CIDP, GBS, and inflammatory myopathies; (d) down-regulation of pathogenic cytokines and adhesion molecules; (e) suppression of T-cell functions; and (f) interference with antigen recognition. Controlled clinical trials have shown that i.v.Ig is effective as first-line therapy in patients with GBS, CIDP, and multifocal motor neuropathy (MMN), and as second-line therapy in DM, MG, LEMS, and SPS. In paraproteinemic IgM anti-MAG (myelin-associated glycoprotein) demyelinating polyneuropathies and inclusion body myositis (IBM), the benefit is variable, marginal, and not statistically significant. i.v.Ig has a remarkably good safety record for long-term administration, however, the following side effects have been observed: mild, infusion-rate-related reactions, such as headaches, myalgia, or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications, such as thromboembolic events and renal tubular necrosis. Future studies are needed to (a) find the appropriate dose and frequency of infusions that maintain a response; (b) address pharmacoeconomics, comparing the high cost of i.v.Ig to the cost of the other therapies, which, although less expensive, cause significantly more long-term side effects; (c) determine why some patients respond better than others; and (d) examine the merits of combining i.v.Ig with other immunosuppressive drugs.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Neuromuscular Diseases Section, National Institute of Neurological Diseases and Stroke, National Institutes of Health, MSC 1382, Room 4N248, Building 10, 10 Center Drive, Bethesda, MD 20892-1382, USA.
| |
Collapse
|
46
|
Guilpain P, Chanseaud Y, Tamby MC, Larroche C, Guillevin L, Kaveri SV, Kazatchkine MD, Mouthon L. Effets immunomodulateurs des immunoglobulines intraveineuses. Presse Med 2004; 33:1183-94. [PMID: 15523290 DOI: 10.1016/s0755-4982(04)98888-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Philippe Guilpain
- Service de médecine interne, Hôpital Cochin, Assistance publique-Hôpitaux de Paris et Université Paris V, Paris
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
Immunoglobulin (Ultravenous, IGIV) is now used in a variety of immune-mediated diseases. Its presumed mechanism of action involves both anti-inflammatory and immunomodulatory activities. A number of dermatologic conditions are believed to be immune mediated and in these disorders, IGIV has shown benefit in reducing symptoms and the need for cortecosteroids or cytotaxic drugs. In many of these diseases, the initial benefits seen in open-labeled trials must be confirmed in controlled clinical trials.
Collapse
Affiliation(s)
- Erwin W Gelfand
- Division of Cell Biology, Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
| |
Collapse
|
48
|
Cavill D, Waterman SA, Gordon TP. Antiidiotypic antibodies neutralize autoantibodies that inhibit cholinergic neurotransmission. ACTA ACUST UNITED AC 2003; 48:3597-602. [PMID: 14674012 DOI: 10.1002/art.11343] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Functional autoantibodies that inhibit M(3) muscarinic receptor (M3R)-mediated neurotransmission have been reported in patients with Sjögren's syndrome (SS) and in patients with scleroderma. Because of limited reports that intravenous immunoglobulin (IVIG) improves dysautonomia in primary SS, we investigated whether IVIG neutralizes the effect of anti-M3R antibodies on colon smooth muscle contractions, in an in vitro functional assay. METHODS IgG obtained from patients with primary SS, patients with rheumatoid arthritis and secondary SS, and patients with scleroderma was tested, before and after coincubation with equimolar amounts of IVIG or its F(ab')(2) and Fc fractions, for the ability to inhibit carbachol-evoked colon smooth muscle contractions. In addition, patient IgG was passed through an IVIG F(ab')(2) column, and unretained IgG was tested for functional activity on colon smooth muscle strips. Purified IgG obtained from healthy adults was also examined for a neutralizing effect on anti-M3R antibody activity. RESULTS Inhibition of colon contractions was mediated by the Fab fraction of patient IgG. Coincubation of IgG from the 3 patient groups with IVIG or its F(ab')(2) fragment neutralized anti-M3R antibody-mediated inhibition of cholinergic smooth muscle contractions. Preabsorption of patient IgG with Sepharose-bound IVIG F(ab')(2) removed the anti-M3R inhibitory activity. In addition, purified IgG from each of 4 healthy adults neutralized the functional autoantibodies. CONCLUSION Anti-M3R antibody activity does not require receptor crosslinking. Antiidiotypic antibodies present in pooled IgG neutralize patient IgG-mediated inhibition of M3R cholinergic neurotransmission, providing a rationale for IVIG as a treatment of autonomic dysfunction in patients with SS and patients with scleroderma. Furthermore, antiidiotypic antibodies in healthy individuals may prevent the emergence of pathogenic anti-M3R autoantibodies.
Collapse
Affiliation(s)
- Dana Cavill
- Flinders University of South Australia, Bedford Park, Australia
| | | | | |
Collapse
|
49
|
Lobbedez T, Comoz F, Renaudineau E, Pujo M, Ryckelynck JP, Hurault de Ligny B. Recurrence of ANCA-positive glomerulonephritis immediately after renal transplantation. Am J Kidney Dis 2003; 42:E2-6. [PMID: 14520649 DOI: 10.1016/s0272-6386(03)00917-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Recurrence of crescentic necrotizing glomerulonephritis after renal transplantation is rare. Successful renal transplantation in patients with antineutrophil cytoplasmic autoantibody (ANCA) glomerulonephritis has been reported. The presence of ANCA at transplantation does not appear to increase the rate of relapse after kidney allografting. Therapy with cyclophosphamide and corticoids usually is effective. We report a case of recurrent perinuclear ANCA crescentic necrotizing glomerulonephritis immediately after renal transplantation that was treated successfully by cyclophosphamide, plasma exchange, and intravenous polyvalent immunoglobulin.
Collapse
Affiliation(s)
- Thierry Lobbedez
- Nephrology and Pathology Department, Caen University Hospital, Caen, France.
| | | | | | | | | | | |
Collapse
|
50
|
Mehta YS, Ghosh K, Badakere SS, Pathare AV, Mohanty D. Role of antiidiotypic antibodies on the clinical course of idiopathic thrombocytopenic purpura. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2003; 142:113-20. [PMID: 12960958 DOI: 10.1016/s0022-2143(03)00104-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The severity and clinical course of idiopathic thrombocytopenic purpura (ITP) vary from patient to patient. The factors responsible for this variation are not well understood. In this study we attempted to evaluate the role of antiidiotypic antibodies in the immunoregulation of the disease. We investigated 114 cases of chronic ITP in adults. We determined antiidiotypic antibodies against antiplatelet antibodies using (a) idiotype-binding enzyme-linked immunosorbent assay (ELISA), (b) paratope-blocking ELISA, and (c) Western blotting. Results indicated that 80.6%, 11.2%, and 8.3% of the patients, respectively, presented with antiidiotypes against antibodies to GPIIb/IIIa, GPIb/IX, and both GPIIb/IIIa and GPIb/IX. More than 70% of the patients who showed high levels of blocking of antiidiotypic antibodies went into complete remission, compared with less than 5% of patients who showed low levels of such antibodies (P <.01). Disease severity was also found to be inversely related (P < 0.01) to the degree of blocking of antiidiotypic antibodies. The results of this study suggest that antiidiotypic antibodies against antiplatelet antibodies are a potential prognostic marker in chronic ITP.
Collapse
Affiliation(s)
- Y S Mehta
- Institute of Immunohaematology, KEM Hospital Campus, Mumbai, India
| | | | | | | | | |
Collapse
|