1
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de-Miguel-Yanes JM, Lopez-de-Andres A, Jimenez-Garcia R, Zamorano-Leon JJ, Carabantes-Alarcon D, Omaña-Palanco R, Hernández-Barrera V, del-Barrio JL, de-Miguel-Diez J, Cuadrado-Corrales N. Association between Hospital-Acquired Pneumonia and In-Hospital Mortality in Solid Organ Transplant Admissions: An Observational Analysis in Spain, 2004-2021. J Clin Med 2023; 12:5532. [PMID: 37685599 PMCID: PMC10488258 DOI: 10.3390/jcm12175532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: To analyze the association between hospital-acquired pneumonia (HAP) and in-hospital mortality (IHM) during hospital admission for solid organ transplant in Spain during 2004-2021. (2) Methods: We used national hospital discharge data to select all hospital admissions for kidney, liver, heart, and lung transplants. We stratified the data according to HAP status. To examine time trends, we grouped data into three consecutive 6-year periods (2004-2009; 2010-2015; and 2016-2021). We assessed in-hospital mortality (IHM) in logistic regression analyses and obtained odds ratios (ORs) with their 95% confidence intervals (CIs). (3) Results: We identified a total of 71,827 transplants (45,262, kidney; 18,127, liver; 4734, heart; and 4598, lung). Two thirds of the patients were men. Overall, the rate of HAP during admission was 2.6% and decreased from 3.0% during 2004-2009 to 2.4% during 2016-2021. The highest rate of HAP corresponded to lung transplant (9.4%), whereas we found the lowest rate for kidney transplant (1.1%). Rates of HAP for liver and heart transplants were 3.8% and 6.3%, respectively. IHM was significantly lower during 2016-2021 compared to 2004-2009 for all types of transplants (ORs (CIs) = 0.65 (0.53-0.79) for kidney; 0.73 (0.63-0.84) for liver; 0.72 (0.59-0.87) for heart; and 0.39 (0.31-0.47) for lung). HAP was associated with IHM for all types of transplants (ORs (CIs) = 4.47 (2.85-9.08) for kidney; 2.96 (2.34-3.75) for liver; 1.86 (1.34-2.57) for heart; and 2.97 (2.24-3.94) for lung). (4) Conclusions: Rates of HAP during admission for solid organ transplant differ depending on the type of transplant. Although IHM during admission for solid organ transplant has decreased over time in our country, HAP persists and is associated with a higher IHM after accounting for potential confounding variables.
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Affiliation(s)
- José M. de-Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Ana Lopez-de-Andres
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
| | - José Javier Zamorano-Leon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
| | - David Carabantes-Alarcon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
| | - Ricardo Omaña-Palanco
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28933 Alcorcón, Spain; (V.H.-B.); (J.L.d.-B.)
| | - Jose Luis del-Barrio
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28933 Alcorcón, Spain; (V.H.-B.); (J.L.d.-B.)
| | - Javier de-Miguel-Diez
- Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Natividad Cuadrado-Corrales
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (J.J.Z.-L.); (D.C.-A.); (R.O.-P.); (N.C.-C.)
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2
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Lahue BJ, Mallick R, Zhang X, Heidt J, Song Y, Koenig AS, Espinoza G. Reduced risk of infections with the intravenous immunoglobulin, IgPro10, in patients at risk of secondary immunodeficiency-related infections. Immunotherapy 2022; 14:1245-1261. [PMID: 35971794 DOI: 10.2217/imt-2022-0142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: Patients with secondary immunodeficiency (SID) are at increased risk of infections and may be treated with immunoglobulin replacement therapy (IgRT). Despite growing efficacy evidence for IgRT in infection prevention in SID, treatment guidelines are not aligned. Materials & methods: A retrospective database analysis was conducted to assess treatment patterns and infection rates in patients at risk of SID-related infections, with or without IgRT (IgPro10) exposure, to evaluate real-world effectiveness of IgRT in infection prevention. Results: Of 11,448 patients included, 222 received IgPro10. B-cell malignancies and solid organ transplants were the predominant underlying conditions. Despite being sicker at baseline, the IgPro10 cohort demonstrated fewer infections post-index than the non-IgRT cohort. Conclusion: IgPro10 may be an effective option for infection prevention in SID.
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3
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Dimitriades V, Butani L. Hypogammaglobulinemia in pediatric kidney transplant recipients. Pediatr Nephrol 2022; 38:1753-1762. [PMID: 36178549 PMCID: PMC10154257 DOI: 10.1007/s00467-022-05757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/27/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Infections remain the most common cause of hospitalization after kidney transplantation, contributing to significant post-transplant morbidity and mortality. There is a growing body of literature that suggests that immunoglobulins may have a significant protective role against post-transplant infections, although the literature remains sparse, inconsistent, and not well publicized among pediatric nephrologists. Of great concern are data indicating a high prevalence of immunoglobulin abnormalities following transplantation and a possible link between these abnormalities and poorer outcomes. Our educational review focuses on the epidemiology and risk factors for the development of immunoglobulin abnormalities after kidney transplantation, the outcomes in patients with low immunoglobulin levels, and studies evaluating possible interventions to correct these immunoglobulin abnormalities.
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Affiliation(s)
- Victoria Dimitriades
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Lavjay Butani
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Room 348, Sacramento, CA, 95817, USA.
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4
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Immohr MB, Böttger C, Aubin H, Westenfeld R, Oehler D, Bruno RR, Dalyanoglu H, Tudorache I, Akhyari P, Lichtenberg A, Boeken U. IgM-enriched immunoglobulin as adjuvant therapy for heart transplant after infection of left ventricular assist devices. ESC Heart Fail 2022; 9:3630-3635. [PMID: 35854478 DOI: 10.1002/ehf2.14074] [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: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 11/07/2022] Open
Abstract
Patients undergoing heart transplantation (HTx) with active infection of left ventricular assist devices (LVAD) are at high risk for postoperative infections. Between 2021 and 2022, five (P1-P5) of a total of n = 44 patients underwent HTx in our department while suffering from LVAD infection. Postoperatively, patients received adjuvant IgM-enriched human intravenous immunoglobulin (IGM-IVIG), consisting of 76% IgG, 12% IgM, and 12% IgA as a novel approach to prevent infective complications. While in P1, P2, and P4, LVAD driveline infection was known before HTx; in P3 and P5, abscess of device pocket was found incidentally during HTx. After a single dose of IGM-IVIG, all patients showed adequate rise in serum immunoglobulins. In the postoperative course, no patient developed infective complications. All patients were successfully discharged and in good condition at the last follow-up. Therefore, IGM-IVIG seems to be an effective adjuvant treatment for patients undergoing HTx with LVAD infections.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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5
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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6
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Hoang J, Krisl J, Moaddab M, Nguyen DT, Graviss EA, Hussain I, Kassi M, Yousefzai R, Kim J, Trachtenberg B, Bhimaraj A, Guha A. Intravenous Immunoglobulin in Heart Transplant Recipients with Mild to Moderate Hypogammaglobulinemia and Infection. Clin Transplant 2021; 36:e14571. [DOI: 10.1111/ctr.14571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Johnny Hoang
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Jill Krisl
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Mozhgon Moaddab
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
- Department of Surgery Houston Methodist Hospital Houston Texas
| | - Imad Hussain
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Rayan Yousefzai
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ju Kim
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
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7
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Coloretti I, Berlot G, Busani S, De Rosa FG, Donati A, Forfori F, Grasselli G, Mirabella L, Tascini C, Viale P, Girardis M. Rationale for Polyclonal Intravenous Immunoglobulin Adjunctive Therapy in COVID-19 Patients: Report of a Structured Multidisciplinary Consensus. J Clin Med 2021; 10:jcm10163500. [PMID: 34441796 PMCID: PMC8396919 DOI: 10.3390/jcm10163500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: Adjunctive therapy with polyclonal intravenous immunoglobins (IVIg) is currently used for preventing or managing infections and sepsis, especially in immunocompromised patients. The pathobiology of COVID-19 and the mechanisms of action of Ig led to the consideration of this adjunctive therapy, including in patients with respiratory failure due to the SARS-CoV-2 infection. This manuscript reports the rationale, the available data and the results of a structured consensus on intravenous Ig therapy in patients with severe COVID-19. Methods: A panel of multidisciplinary experts defined the clinical phenotypes of COVID-19 patients with severe respiratory failure and, after literature review, voted for the agreement on the rationale and the potential role of IVIg therapy for each phenotype. Due to the scarce evidence available, a modified RAND/UCLA appropriateness method was used. Results: Three different phenotypes of COVID-19 patients with severe respiratory failure were identified: patients with an abrupt and dysregulated hyperinflammatory response (early phase), patients with suspected immune paralysis (late phase) and patients with sepsis due to a hospital-acquired superinfection (sepsis by bacterial superinfection). The rationale for intravenous Ig therapy in the early phase was considered uncertain whereas the panelists considered its use in the late phase and patients with sepsis/septic shock by bacterial superinfection appropriate. Conclusion: As with other immunotherapies, IVIg adjunctive therapy may have a potential role in the management of COVID-19 patients. The ongoing trials will clarify the appropriate target population and the true effectiveness.
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Affiliation(s)
- Irene Coloretti
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | - Giorgio Berlot
- Anestesia and Intensive Care Department, University Hospital of Trieste, 34127 Trieste, Italy;
| | - Stefano Busani
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | | | - Abele Donati
- Anaesthesia and Intensive Care Department, University Hospital of Ancona, 60127 Ancona, Italy;
| | - Francesco Forfori
- Anaesthesia and Intensive Care Department, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Giacomo Grasselli
- Anaesthesia and Intensive Care Department, University Hospital of Milan, 20122 Milano, Italy;
| | - Lucia Mirabella
- Anaesthesia and Intensive Care Department, University Hospital of Foggia, 71122 Foggia, Italy;
| | - Carlo Tascini
- Infectious Disease Department, University Hospital of Udine, 33100 Udine, Italy;
| | - Pierluigi Viale
- Infectious Disease Department, University Hospital of Bologna, 40126 Bologna, Italy;
| | - Massimo Girardis
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
- Correspondence:
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8
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Pavlakou P, Papasotiriou M, Ntrinias T, Kourakli A, Bratsiakou A, Goumenos DS, Papachristou E. Case Report: Kidney Transplantation in a Patient With Acquired Agammaglobulinemia and SLE. Issues and Challenges. Front Med (Lausanne) 2021; 8:665475. [PMID: 33777986 PMCID: PMC7994764 DOI: 10.3389/fmed.2021.665475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Lupus nephritis in the context of Systemic Lupus Erythematosus (SLE) is characterized by an unpredicted course with remissions and flare-ups. Among others, it remains a significant cause of end-stage kidney disease (ESKD) in relatively young patients. Therapeutic regimens with newer immunosuppressive agents have been introduced in order to control SLE clinical manifestations more efficiently and limit organ damage induced by immune complex formation and sustained inflammation. Treatment is usually long-term, and the cumulative impact of immunosuppression is expressed through the increased frequency of infections and neoplasms. However, if the observed immunity dysregulation is secondary and pharmaceutically induced or there is a pre-existing, primary immunodeficiency that shares common pathogenetic pathways with SLE's autoimmunity is not always clear. Herein, we present the case of a 39-year-old woman, that reached ESKD due to lupus nephritis. After an upper respiratory cytomegalovirus (CMV) infection and concomitant CMV reactivations the investigation revealed significant immunodeficiency. Not long after the initiation of intravenous immunoglobulin (IVIG) administration, patient received a cadaveric kidney transplant. IVIG was continued along with standard immunosuppression so that both recurrent infections and allograft rejection are avoided. Patient is closely monitored, and her post-transplant course is remarkably satisfying so far. ESKD patients with immunodeficiency syndromes should not be excluded by definition from kidney transplantation.
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Affiliation(s)
- Paraskevi Pavlakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Marios Papasotiriou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Theodoros Ntrinias
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Alexandra Kourakli
- Hematology Division, Department of Internal Medicine, University Hospital of Patras, Achaia, Greece
| | - Adamantia Bratsiakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Dimitrios S Goumenos
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Evangelos Papachristou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
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9
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Sarmiento E, Jimenez M, di Natale M, Rodriguez-Ferrero M, Anaya F, Lopez-Hoyos M, Rodrigo E, Arias M, Perello M, Seron D, Karanovic B, Ezzahouri I, Mezzano S, Jaramillo M, Calahorra L, Alarcon A, Navarro J, Muñoz P, Carbone J. Secondary antibody deficiency is associated with development of infection in kidney transplantation: Results of a multicenter study. Transpl Infect Dis 2020; 23:e13494. [PMID: 33064917 DOI: 10.1111/tid.13494] [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: 08/08/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND We performed a multicenter study to assess the association between secondary antibody deficiency (immunoglobulin G [IgG] hypogammaglobulinemia combined with low levels of specific antibodies) and development of infection in kidney transplantation. METHODS We prospectively analyzed 250 adult kidney recipients at four centers. The assessment points were before transplantation and 7 and 30 days after transplantation. The immune parameters were as follows: IgG, IgA, and IgM and complement factors C3 and C4 tested by nephelometry; specific IgG antibodies to cytomegalovirus (CMV) and IgG and IgG2 antibodies to pneumococcal polysaccharide (anti-PPS) determined using enzyme-linked immunosorbent assay. The clinical follow-up period lasted 6 months. The clinical outcomes were CMV disease and recurrent bacterial infections requiring antimicrobial therapy. STATISTICS Multivariate logistic regression. RESULTS At day 7, IgG hypogammaglobulinemia (IgG levels < 700 mg/dL) combined with low IgG anti-CMV antibody titers (defined as levels < 10 000 units) was present in 12% of kidney recipients. IgG hypogammaglobulinemia combined with low IgG anti-PPS antibody titers (defined as levels < 10 mg/dL) at 1 month after kidney transplantation were recorded in 16% of patients. At day 7 the combination of IgG hypogammaglobulinemia and low anti-CMV titers was independently associated with the development of CMV disease (odds ratio [OR], 6.95; 95% confidence interval [CI], 1.17-41.31; P = .033). At day 30 after transplantation, the combination of IgG < 700 mg/dL and IgG anti-PPS < 10 mg/dL, was independently associated with recurrent bacterial infection (OR, 5.942; 95% CI, 1.943-18.172; P = .002). CONCLUSION In a prospective multicenter study, early immunologic monitoring of secondary antibody deficiency proved useful for the identification of kidney recipients who developed severe infection.
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Affiliation(s)
- Elizabeth Sarmiento
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Jimenez
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marisa di Natale
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Fernando Anaya
- Nephrology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Marcos Lopez-Hoyos
- Immunology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain.,Histocompatibility Testing Laboratory, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Manuel Arias
- Nephrology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Manel Perello
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Seron
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Boris Karanovic
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ikram Ezzahouri
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Sergio Mezzano
- Division of Nephrology, School of Medicine, Universidad Austral, Valdivia, Chile
| | - Maria Jaramillo
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Medicine Institute, Universidad Austral, Valdivia, Chile
| | - Leticia Calahorra
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Alba Alarcon
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Joaquin Navarro
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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10
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Fujino T, Kumai Y, Nitta D, Holzhauser L, Nguyen A, Lourenco L, Rodgers D, Raikhelkar J, Kim G, Sayer G, Uriel N. Hypogammaglobulinemia following heart transplantation: Prevalence, predictors, and clinical importance. Clin Transplant 2020; 34:e14087. [PMID: 32955148 DOI: 10.1111/ctr.14087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/09/2020] [Accepted: 09/08/2020] [Indexed: 01/14/2023]
Abstract
Hypogammaglobulinemia (HGG) can occur following solid organ transplantation. However, there are limited data describing the prevalence, risk factors, and clinical outcomes associated with HGG following heart transplantation. We retrospectively reviewed data of 132 patients who had undergone heart transplantation at our institution between April 2014 and December 2018. We classified patients into three groups based on the lowest serum IgG level post-transplant: normal (≥700 mg/dL), mild HGG (≥450 and <700 mg/dL), and severe HGG (<450 mg/dL). We compared clinical outcomes from the date of the lowest IgG level. Mean age was 57 (47, 64) years, and 94 (71%) patients were male. Prevalence of severe HGG was the highest (27%) at 3-6 months following heart transplantation and then decreased to 5% after 1 year. Multivariate analysis showed that older age and Caucasian race were independent risk factors for HGG. Overall survival was comparable between the groups; however, survival free of infection was 73%, 60%, and 45% at 1 year in the normal, mild HGG, and severe HGG groups, respectively (P = .013). In conclusion, there is a high prevalence of HGG in the early post-heart transplant period that decreases over time. HGG is associated with an increased incidence of infection.
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Affiliation(s)
- Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Yuto Kumai
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Daisuke Nitta
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Luise Holzhauser
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Laura Lourenco
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
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11
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Roberts MB, Fishman JA. Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression". Clin Infect Dis 2020; 73:e1302-e1317. [PMID: 32803228 DOI: 10.1093/cid/ciaa1189] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/14/2022] Open
Abstract
Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.
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Affiliation(s)
- Matthew B Roberts
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA
| | - Jay A Fishman
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA.,Harvard Medical School, Boston, MA
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12
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Fernández-Ruiz M, López-Medrano F, Aguado JM. Predictive tools to determine risk of infection in kidney transplant recipients. Expert Rev Anti Infect Ther 2020; 18:423-441. [PMID: 32084326 DOI: 10.1080/14787210.2020.1733976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Infection represents a major complication after kidney transplantation (KT). Therapeutic drug monitoring is essentially the only approach for the adjustment of immunosuppression in current practice, with suboptimal results. The implementation of immune monitoring strategies may contribute to minimizing the risk of adverse events attributable to over-immunosuppression without compromising graft outcomes.Areas covered: The present review (based on PubMed/MEDLINE searches from database inception to November 2019) is focused on immune biomarkers with no antigen specificity (non-pathogen-specific), including serum levels of immunoglobulins and complement factors, peripheral blood lymphocyte subpopulations, soluble CD30, intracellular ATP production by stimulated CD4+ T-cells, and other cell-based immune assays. We also summarized recent advances in the use of replication kinetics of latent viruses to assess the functionality of T-cell immunity, with focus on the nonpathogenic anelloviruses. Finally, the composite risk scores reported in the literature are critically discussed.Expert opinion: Notable efforts have been made to develop an enlarging repertoire of immune biomarkers and prediction models, although most of them still lack technical standardization and external validation. Preventive interventions based on these tools (prolongation of prophylaxis, tapering of immunosuppression, or immunoglobulin replacement therapy in hypogammaglobulinemic patients) remain to be defined, ideally in the context of controlled trials.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
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13
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Weston MW, Rinde-Hoffman D, Lopez-Cepero M. Monitoring cell-mediated immunity during immunosuppression reduction in heart transplant recipients with severe systemic infections. Clin Transplant 2020; 34:e13809. [PMID: 32003048 DOI: 10.1111/ctr.13809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Treatment for severe systemic infections in heart transplantation is reduction in immunosuppression while treating the infection. An assay that measures adenosine triphosphate production in activated lymphocytes (ImmuKnow® ) objectively monitors cellular immunity of transplant recipients. In this study, we used ImmuKnow® to adjust immunosuppression in heart transplant recipients with severe systemic infections. METHODS Heart transplant recipients were followed with ImmuKnow® at the time of biopsy and diagnosis of systemic infection. Patients who developed an infection were monitored by ImmuKnow® assay with adjustments in immunosuppression based upon the results of the assay. Maintenance immunosuppression was reinstituted when the ImmuKnow® increased to >225 ng/mL of ATP. RESULTS Two or more ImmuKnow® assays were performed in 80 patients. Thirteen patients developed severe systemic infections. ImmuKnow® mean value at the time of diagnosis of infection was 109 ± 49.2 ng/mL. Reduction in immunosuppression and treatment of infection resulted in normalization of ImmuKnow® level, resolution of infection, and no episodes of rebound rejection. CONCLUSION Heart transplant recipients with severe systemic infections presented with a decreased ImmuKnow® , suggesting over immunosuppression. ImmuKnow® can be used as an objective measurement in withdrawing immunosuppression in heart transplant recipients with severe systemic infections.
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14
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Bourassa-Blanchette S, Patel V, Knoll GA, Hutton B, Fergusson N, Bennett A, Tay J, Cameron DW, Cowan J. Clinical outcomes of polyvalent immunoglobulin use in solid organ transplant recipients: A systematic review and meta-analysis - Part II: Non-kidney transplant. Clin Transplant 2019; 33:e13625. [PMID: 31162852 DOI: 10.1111/ctr.13625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
Abstract
Immunoglobulin (IG) is commonly used to desensitize and treat antibody-mediated rejection in solid organ transplant (SOT) recipients. The impact of IG on other outcomes such as infection, all-cause mortality, graft rejection, and graft loss is not clear. We conducted a similar systematic review and meta-analysis to our previously reported Part I excluding kidney transplant. A comprehensive literature review found 16 studies involving the following organ types: heart (6), lung (4), liver (4), and multiple organs (2). Meta-analysis could only be performed on mortality outcome in heart and lung studies due to inadequate data on other outcomes. There was a significant reduction in mortality (OR 0.34 [0.17-0.69]; 4 studies, n = 455) in heart transplant with hypogammaglobulinemia receiving IVIG vs no IVIG. Mortality in lung transplant recipients with hypogammaglobulinemia receiving IVIG was comparable to those of no hypogammaglobulinemia (OR 1.05 [0.49, 2.26]; 2 studies, n = 887). In summary, IVIG targeted prophylaxis may decrease mortality in heart transplant recipients as compared to those with hypogammaglobulinemia not receiving IVIG, or improve mortality to the equivalent level with those without hypogammaglobulinemia in lung transplant recipients, but there is a lack of data to support physicians in making decisions around using immunoglobulins in all SOT recipients for infection prophylaxis.
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Affiliation(s)
- Samuel Bourassa-Blanchette
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Vishesh Patel
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg A Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Renal Transplantation, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicholas Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jason Tay
- Blood and Marrow Transplant Program, Alberta Health Sciences, Calgary, Alberta, Canada
| | - D William Cameron
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Juthaporn Cowan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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15
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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16
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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17
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Sarmiento E, Cifrian J, Calahorra L, Bravo C, Lopez S, Laporta R, Ussetti P, Sole A, Morales C, de Pablos A, Jaramillo M, Ezzahouri I, García S, Navarro J, Lopez-Hoyos M, Carbone J. Monitoring of early humoral immunity to identify lung recipients at risk for development of serious infections: A multicenter prospective study. J Heart Lung Transplant 2018; 37:1001-1012. [DOI: 10.1016/j.healun.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
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18
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Onwuemene OA, Grambow SC, Patel CB, Mentz RJ, Milano CA, Rogers JG, Metjian AD, Arepally GM, Ortel TL. Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study. J Clin Apher 2018; 33:469-479. [PMID: 29524240 PMCID: PMC6105382 DOI: 10.1002/jca.21622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/19/2018] [Accepted: 02/24/2018] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Limited data are available describing indications for and outcomes of therapeutic plasma exchange (TPE) in cardiac transplantation. METHODS In a retrospective study of patients who underwent cardiac transplantation at Duke University Medical Center from 2010 to 2014, we reviewed 3 TPE treatment patterns: a Single TPE procedure within 24 h of transplant; Multiple TPE procedures initiated within 24 h of transplant; and 1 or more TPE procedures beginning >24 h post-transplant. Primary and secondary outcomes were overall survival (OS) and TPE survival (TS), respectively. RESULTS Of 313 patients meeting study criteria, 109 (35%) underwent TPE. TPE was initiated in 82 patients within 24 h, 40 (37%) receiving a single procedure (Single TPE), and 42 (38%) multiple procedures (Multiple TPE). Twenty-seven (25%) began TPE >24 h after transplant (Delayed TPE). The most common TPE indication was elevated/positive panel reactive or human leukocyte antigen antibodies (32%). With a median follow-up of 49 months, the non-TPE treated and Single TPE cohorts had similar OS (HR 1.08 [CI, 0.54, 2.14], P = .84), while the Multiple and Delayed TPE cohorts had worse OS (HR 2.62 [CI, 1.53, 4.49] and HR 1.98 [CI, 1.02, 3.83], respectively). The Multiple and Delayed TPE cohorts also had worse TS (HR 2.59 [CI, 1.31, 5.14] and HR 3.18 [CI, 1.56, 6.50], respectively). Infection rates did not differ between groups but was independently associated with OS (HR 2.31 [CI, 1.50, 3.54]). CONCLUSIONS TPE is an important therapeutic modality in cardiac transplant patients. Prospective studies are needed to better define TPE's different roles in this patient population.
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Affiliation(s)
- Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Steven C Grambow
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph G Rogers
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ara D Metjian
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gowthami M Arepally
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
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19
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Lee M, Barr J, Kribs S, Filler G. Strategies to reduce line infections in a small child with homozygous familial hypercholesterolaemia who cannot yet receive LDL apheresis. BMJ Case Rep 2017; 2017:bcr-2017-219538. [PMID: 28866629 DOI: 10.1136/bcr-2017-219538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with homozygous familial hypercholesterolaemia are optimally treated with low-density lipoprotein apheresis. Young patients who do not meet a weight threshold (25 kg) receive regular plasmapheresis. This approach may remove excessive immunoglobulins and vascular access set-up can be challenging. We report the case of a 4 year-old child who exhibited repeated septic infections (5 in 6 months) and had recurrent access issues before two interventions were implemented: (1) the percutaneous central venous line was modified to two implanted paediatric ports, and (2) the patient started receiving two bags of Octaplasma at the end of each plasmapheresis treatment to account for the excessive loss of immunoglobulins. For the paediatric plasmapheresis access port, a 19-gauge Huber needle had to be used for the arterial port to prevent the collapse of the extension. These two simple changes have left the patient infection-free for 9 months.
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Affiliation(s)
- Misan Lee
- Department of Paediatrics, University of Western Ontario, Ontario, Canada
| | - Janet Barr
- Department of Paediatrics, University of Western Ontario, Ontario, Canada
| | - Stewart Kribs
- Department of Radiology, University of Western Ontario, Ontario, Canada
| | - Guido Filler
- Department of Paediatrics, University of Western Ontario, Ontario, Canada
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20
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Aiba N, Shiraki A, Yajima M, Oyama Y, Yoshida Y, Ohno A, Yamada H, Takemoto M, Daikoku T, Shiraki K. Interaction of Immunoglobulin with Cytomegalovirus-Infected Cells. Viral Immunol 2017; 30:500-507. [PMID: 28598267 DOI: 10.1089/vim.2016.0151] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) is used to treat or prevent severe viral infection, especially cytomegalovirus (CMV) infections. IVIG was characterized to understand its interaction with CMV-infected cells. IVIG retarded CMV spread and reduced virus yields depending on the neutralizing (NT) antibody titer. Immediate early protein synthesis was reduced by IVIG in 3 to 15 h, and IVIG specifically reduced the ratio of 66/68k protein synthesis among immediate early proteins in an NT antibody-dependent manner between 4 and 8 h after infection, indicating that antigenic modulation of CMV-infected cells by IVIG reduced viral protein synthesis and virus production. The half-life of antibody bound to CMV-infected cells was 3.8 h. NT antibody titers to varicella-zoster virus (VZV) and CMV in IVIG were dose dependently absorbed by cells infected with VZV and CMV, respectively, but the antibody titers to CMV and VZV, respectively, were not affected. NT antibody in 0.3 mL of IVIG (15 mg) was specifically absorbed by 108 CMV-infected cells and 107 VZV-infected cells, suggesting that the NT antibody in IVIG might be inactivated by one-tenth of a similar volume of CMV-infected or VZV-infected cells. Various antiviral activities of IVIG may contribute to control and alleviation of CMV infection.
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Affiliation(s)
- Nobuyasu Aiba
- 1 Health Care Center, Takaoka Fushiki Hospital , Takaoka City, Japan
| | - Atsuko Shiraki
- 2 Department of Virology, University of Toyama , Toyama City, Japan
| | - Misako Yajima
- 2 Department of Virology, University of Toyama , Toyama City, Japan
| | - Yukari Oyama
- 2 Department of Virology, University of Toyama , Toyama City, Japan
| | | | - Ayumu Ohno
- 2 Department of Virology, University of Toyama , Toyama City, Japan
| | - Hiroshi Yamada
- 2 Department of Virology, University of Toyama , Toyama City, Japan
| | - Masaya Takemoto
- 3 Faculty of Pharmaceutical Sciences, Hokuriku University , Kanazawa City, Japan
| | - Tohru Daikoku
- 3 Faculty of Pharmaceutical Sciences, Hokuriku University , Kanazawa City, Japan
| | - Kimiyasu Shiraki
- 2 Department of Virology, University of Toyama , Toyama City, Japan
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21
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Jolles S, Chapel H, Litzman J. When to initiate immunoglobulin replacement therapy (IGRT) in antibody deficiency: a practical approach. Clin Exp Immunol 2017; 188:333-341. [PMID: 28000208 DOI: 10.1111/cei.12915] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
Primary antibody deficiencies (PAD) constitute the majority of all primary immunodeficiency diseases (PID) and immunoglobulin replacement forms the mainstay of therapy for many patients in this category. Secondary antibody deficiencies (SAD) represent a larger and expanding number of patients resulting from the use of a wide range of immunosuppressive therapies, in particular those targeting B cells, and may also result from renal or gastrointestinal immunoglobulin losses. While there are clear similarities between primary and secondary antibody deficiencies, there are also significant differences. This review describes a practical approach to the clinical, laboratory and radiological assessment of patients with antibody deficiency, focusing on the factors that determine whether or not immunoglobulin replacement should be used. The decision to treat is more straightforward when defined diagnostic criteria for some of the major PADs, such as common variable immunodeficiency disorders (CVID) or X-linked agammaglobulinaemia (XLA), are fulfilled or, indeed, when there is a very low level of immunoglobulin production in association with an increased frequency of severe or recurrent infections in SAD. However, the presentation of many patients is less clear-cut and represents a considerable challenge in terms of the decision whether or not to treat and the best way in which to assess the outcome of therapy. This decision is important, not least to improve individual quality of life and reduce the morbidity and mortality associated with recurrent infections but also to avoid inappropriate exposure to blood products and to ensure that immunoglobulin, a costly and limited resource, is used to maximal benefit.
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Affiliation(s)
- S Jolles
- Immunodeficiency Centre for Wales, Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - H Chapel
- Department of Clinical Immunology, University of Oxford, UK
| | - J Litzman
- Department of Clinical Immunology and Allergology, St Annes's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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