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Danieli MG, Antonelli E, Auria S, Buti E, Shoenfeld Y. Low-dose intravenous immunoglobulin (IVIg) in different immune-mediated conditions. Autoimmun Rev 2023; 22:103451. [PMID: 37748542 DOI: 10.1016/j.autrev.2023.103451] [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: 08/30/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
IVIg has been used for a long time as a replacement therapy for primary and secondary immunodeficiencies. Beside this supplementary role, when used at higher doses (i.e., 2 g/kg/monthly) it exerts an immunomodulatory role able to control multiple autoimmune and systemic inflammatory diseases. Several mechanisms of action have been described and hypothesized, nonetheless a synergistic action on the different component of the immune response seems to be crucial. The other side of the coin are the costs which showed an increase during the years due to the production of highly purified preparations which limit side reactions. This renders the product not easily accessible especially for low-income countries. Moreover, it is based on plasma donations that experienced a significant shrinkage after the COVID-19 pandemic and the consequences are still impactful. Due to the above-mentioned problems different authors tried to find out if a lower dosage of IVIg (< 2 g/kg/monthly) might exert an immunoregulatory role. In this review we aimed to summarize the current literature about a possible beneficial effect of a lower dosage of IVIg in multiple conditions that would help to treat a vast majority of patients. Even though in some cases (e.g., Kawasaki disease and immune thrombocytopenia) results are promising, for other conditions more research is needed.
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Affiliation(s)
- Maria Giovanna Danieli
- SOS Immunologia delle Malattie Rare e dei Trapianti, AOU delle Marche e Università Politecnica delle Marche, Ancona, Italy; Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy.
| | - Eleonora Antonelli
- Postgraduate School of Internal Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Stefania Auria
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy
| | - Elena Buti
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Reichman University Herzliya, Israel.
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2
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Giouleka S, Tsakiridis I, Zachomitros F, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Fetal and neonatal alloimmune thrombocytopenia: A rare case report of prenatal treatment. Clin Case Rep 2023; 11:e7806. [PMID: 37614290 PMCID: PMC10442467 DOI: 10.1002/ccr3.7806] [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: 05/08/2023] [Revised: 06/17/2023] [Accepted: 08/07/2023] [Indexed: 08/25/2023] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare but serious condition. The first-line antenatal management of FNAIT consists of weekly IVIG with or without corticosteroids, ideally starting before 16 weeks of gestation.
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Affiliation(s)
- Sonia Giouleka
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Fotios Zachomitros
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Ioannis Kalogiannidis
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
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3
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [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: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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Lieberman L, Greinacher A, Murphy MF, Bussel J, Bakchoul T, Corke S, Kjaer M, Kjeldsen-Kragh J, Bertrand G, Oepkes D, Baker JM, Hume H, Massey E, Kaplan C, Arnold DM, Baidya S, Ryan G, Savoia H, Landry D, Shehata N. Fetal and neonatal alloimmune thrombocytopenia: recommendations for evidence-based practice, an international approach. Br J Haematol 2019; 185:549-562. [PMID: 30828796 DOI: 10.1111/bjh.15813] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) may result in severe bleeding, particularly fetal and neonatal intracranial haemorrhage (ICH). As a result, FNAIT requires prompt identification and treatment; subsequent pregnancies need close surveillance and management. An international panel convened to develop evidence-based recommendations for diagnosis and management of FNAIT. A rigorous approach was used to search, review and develop recommendations from published data for: antenatal management, postnatal management, diagnostic testing and universal screening. To confirm FNAIT, fetal human platelet antigen (HPA) typing, using non-invasive methods if quality-assured, should be performed during pregnancy when the father is unknown, unavailable for testing or heterozygous for the implicated antigen. Women with a previous child with an ICH related to FNAIT should be offered intravenous immunoglobulin (IVIG) infusions during subsequent affected pregnancies as early as 12 weeks gestation. Ideally, HPA-selected platelets should be available at delivery for potentially affected infants and used to increase the neonatal platelet count as needed. If HPA-selected platelets are not immediately available, unselected platelets should be transfused. FNAIT studies that optimize antenatal and postnatal management, develop risk stratification algorithms to guide management and standardize laboratory testing to identify high risk pregnancies are needed.
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Affiliation(s)
- Lani Lieberman
- University of Toronto, Toronto, Canada.,University Health Network, Toronto, Canada
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Michael F Murphy
- National Health Service (NHS) Blood and Transplant and the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, United Kingdom
| | | | | | | | - Mette Kjaer
- Finnmark Hospital Trust, Hammerfest, Norway.,University Hospital of North Norway, Tromsø, Norway
| | - Jens Kjeldsen-Kragh
- University Hospital of North Norway, Tromsø, Norway.,University and Regional Laboratories Region Skåne, Lund, Sweden
| | - Gerald Bertrand
- Blood Center of Brittany - EFS L'Établissement Français du Sang, Rennes, France
| | - Dick Oepkes
- Leiden University Medical Center, Leiden, the Netherlands
| | - Jillian M Baker
- Hospital for Sick Children and St. Michael's Hospital, Toronto, Canada
| | - Heather Hume
- CHU Sainte-Justine, Université de Montréal, Montréal, Canada
| | | | - Cécile Kaplan
- Retired and formerly Institut National de la Transfusion Sanguine, Paris, France
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, McMaster University and Canadian Blood Services, Hamilton, Canada
| | - Shoma Baidya
- Australian Red Cross Blood Service, Brisbane, Australia
| | - Greg Ryan
- University of Toronto, Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada
| | | | | | - Nadine Shehata
- University of Toronto, Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada.,Canadian Blood Services, Toronto, Canada
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Winkelhorst D, Oepkes D. Foetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2019; 58:15-27. [PMID: 30827816 DOI: 10.1016/j.bpobgyn.2019.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022]
Abstract
Foetal or neonatal thrombocytopenia results from alloimmunisation during pregnancy. Maternal alloantibodies can be formed following exposure to paternally derived human platelet antigens (HPAs) on foetal platelets, in case of incompatible HPA type. These alloantibodies are of the immunoglobulin G subclass and can therefore enter the foetal circulation through active placental transport mediated by the neonatal Fc-receptor. After entering the foetal circulation, these alloantibodies can cause destruction of foetal platelets and potentially damage other foetal cells containing the specific antigen. Subsequent clinical presentation in foetuses or neonates can vary widely, from an asymptomatic thrombocytopenia to a broad spectrum of bleeding complications. Most frequently encountered are minor skin haemorrhages, such as hematomas or petechiae, but also more devastating haemorrhages can occur. Of these, an intracranial haemorrhage is the most feared complication because of its high risk of life-long major neurological handicaps or perinatal death.
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Affiliation(s)
- Dian Winkelhorst
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
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6
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Shemer A, Kivity S, Shoenfeld Y. Clinical indications for intravenous immunoglobulin utilization in a tertiary medical center: a 9-year retrospective study. Transfusion 2017; 58:430-438. [PMID: 29193136 DOI: 10.1111/trf.14427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/08/2017] [Accepted: 10/08/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intravenous immunoglobulins (IVIG) are a biologic product originally developed to treat immunocompromised patients. In the past decades, there has been increased utilization of IVIG in autoimmune conditions. The objectives were to evaluate the clinical use of IVIG in the largest tertiary medical center in Israel and to determine top uses, estimate off-label usage, and assess consumption of this blood product. STUDY DESIGN AND METHODS We conducted an observational, retrospective study involving all patients who received IVIG from 2007 through 2015. Subjects were classified into five groups according to the indication for treatment. RESULTS A total of 1117 patients were identified. The mean (±SD) ages of adults and children were 55 ± 17 and 8 ± 7 years, respectively. Most common indication for treatment were immune-mediated conditions (54%), followed by secondary immunodeficiency (28%), primary immunodeficiency (10%), infections (4%), and miscellaneous (4%). The main immune-mediated conditions treated were hematologic disorders (305 patients, 27%), neurologic disorders (219 patients, 20%), and rheumatologic conditions (79 patients, 7%). Overall, a significant change in study period was observed in the number of patients (p < 0.001), consumption of IVIG (p < 0.01), and amount of IVIG administered per patient (p < 0.01). Fifty-six percent of the IVIG infusions were given for off-label Food and Drug Administration (FDA) indications. CONCLUSION In this study, we demonstrated that immune-mediated conditions represent the majority of indications for treatment with IVIG. We observed a 417% increase in IVIG administration (g) over time, attributed mainly to autoimmune diseases. Many indications are still off-label according to FDA recommendations.
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Affiliation(s)
- Asaf Shemer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Zabludowicz Center for Autoimmune Diseases
| | - Shaye Kivity
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Zabludowicz Center for Autoimmune Diseases.,Department of Medicine A, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Zabludowicz Center for Autoimmune Diseases
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7
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Kjeldsen-Kragh J. Screening for fetal and neonatal alloimmune thrombocytopenia: is it possible and what are the potential outcomes? ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine; University and Regional Laboratories Region Skåne; Lund Sweden
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8
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Herrmann A, Samelson-Jones BJ, Brake S, Samelson R. IVIG-Associated Maternal Pancytopenia during Treatment for Neonatal Alloimmune Thrombocytopenia. AJP Rep 2017; 7:e197-e200. [PMID: 28970962 PMCID: PMC5621970 DOI: 10.1055/s-0037-1607055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/22/2017] [Indexed: 11/13/2022] Open
Abstract
Background Treatment for neonatal alloimmune thrombocytopenia (NAIT) primarily involves maternal administration of intravenous immunoglobulin (IVIG) therapy and prednisone according to protocols based on risk stratification. While IVIG is generally well tolerated, hematologic side effects are a potential complication. Case We present the successful management of a rare complication of maternal pancytopenia following standard IVIG treatment. Diagnosis was made during routine obstetric exams. Management included reducing IVIG dosage and adding daily prednisone. Additionally, infusion Lots possibly associated with the event were identified and avoided. Interventions resulted in the resolution of pancytopenia and the birth of a healthy infant without thrombocytopenia. Conclusion Pancytopenia is a rare complication of IVIG treatment in women with pregnancies complicated by NAIT. Serial complete blood counts at the time of treatment would allow for early detection and timely management of the patient. Additionally, limiting the number of infusion Lots may decrease the chance of the described complications.
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Affiliation(s)
- Alyssa Herrmann
- Albany Medical College, Albany, New York.,The Cleveland Clinic Women's Health Institute, Cleveland, Ohio
| | | | - Sami Brake
- New York Hematology and Oncology, Albany, New York
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Winkelhorst D, Oepkes D, Lopriore E. Fetal and neonatal alloimmune thrombocytopenia: evidence based antenatal and postnatal management strategies. Expert Rev Hematol 2017. [PMID: 28644735 DOI: 10.1080/17474086.2017.1346471] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a relatively rare but potentially lethal disease, leading to severe bleeding complications in 1 in 11.000 newborns. It is the leading cause of thrombocytopenia in healthy term-born neonates. Areas covered: This review summarizes the antenatal as well as postnatal treatment, thus creating a complete overview of all possible management strategies for FNAIT. Expert commentary: The optimal antenatal therapy in order to prevent bleeding complications in pregnancies complicated by FNAIT is non-invasive treatment with weekly intravenous immunoglobulin (IVIG). Based on risk stratification, weekly doses of IVIG of 0.5 or 1.0g/kg should be administered started early in the second in high risk cases or at the end of the second trimester in low risk cases. The optimal postnatal treatment depends on the platelet count and the clinical condition of the newborn. Prompt administration of compatible platelet transfusion is the first treatment of choice in case of severe thrombocytopenia or active bleeding. In case matched platelets are not directly available, random platelets can also be administered initially to gain time until matched platelets are available. In case of persistent thrombocytopenia despite transfusions, IVIG 1.0-2.0g/kg can be administered.
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Affiliation(s)
- Dian Winkelhorst
- a Division of Fetal Therapy, Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands.,b Department Immunohematology Experimental , Sanquin , Amsterdam , The Netherlands
| | - Dick Oepkes
- a Division of Fetal Therapy, Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Enrico Lopriore
- c Division of Neonatology, Department of Pediatrics , Leiden University Medical Center , Leiden , The Netherlands
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11
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Skariah A, Sung N, Salazar Garcia MD, Wu L, Tikoo A, Gilman-Sachs A, Kwak-Kim J. Low-dose prednisone and immunoglobulin G treatment for woman at risk for neonatal alloimmune thrombocytopenia and T helper 1 immunity. Am J Reprod Immunol 2017; 77. [PMID: 28240400 DOI: 10.1111/aji.12649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/17/2017] [Indexed: 01/08/2023] Open
Abstract
PROBLEM Fetal and neonatal alloimmune thrombocytopenia is an alloimmune disorder resulting from platelet opsonization by maternal antibodies that destroy fetal platelets. As there is no antenatal screening or immunization to prevent sensitization, selection of high-risk population or the prevention of antenatal sensitization is significantly limited. METHOD OF STUDY (i) A case report of ante- and postnatal management of a woman with paternal homozygosity for human platelet antigen-1(HPA) incompatibility. (ii) A retrospective case-control study of 11 confirmed FNAIT patients, 8 possible-FNAIT women, and 10 women with confirmed ITP. RESULT Antenatal screening, prevention of maternal sensitization by serial monitoring and immunosuppression with prednisone and intravenous immunoglobulin G (IVIG) infusion resulted in two successful pregnancies without sensitization. CONCLUSION Screening for couples at risk and prednisone and/or IVIG treatment is an option for women with paternal homozygosity for offending HPA antigen to prevent antenatal sensitization. HPA incompatibility is associated with increased Th1 immunity and NK cell cytotoxicity.
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Affiliation(s)
- Annie Skariah
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Nayoung Sung
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Maria D Salazar Garcia
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Li Wu
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Anjali Tikoo
- Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Alice Gilman-Sachs
- Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Joanne Kwak-Kim
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA.,Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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