1
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Le Coz C, Trofa M, Butler DL, Yoon S, Tian T, Reid W, Cruz Cabrera E, Knox AVC, Khanna C, Sullivan KE, Heimall J, Takach P, Fadugba OO, Lawrence M, Jyonouchi S, Hakonarson H, Wells AD, Handler S, Zur KB, Pillai V, Gildersleeve JC, Romberg N. The common variable immunodeficiency IgM repertoire narrowly recognizes erythrocyte and platelet glycans. J Allergy Clin Immunol 2024:S0091-6749(24)00418-4. [PMID: 38692308 DOI: 10.1016/j.jaci.2024.04.018] [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: 08/04/2023] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Autoimmune cytopenias (AICs) regularly occur in profoundly IgG-deficient patients with common variable immunodeficiency (CVID). The isotypes, antigenic targets, and origin(s) of their disease-causing autoantibodies are unclear. OBJECTIVE We sought to determine reactivity, clonality, and provenance of AIC-associated IgM autoantibodies in patients with CVID. METHODS We used glycan arrays, patient erythrocytes, and platelets to determine targets of CVID IgM autoantibodies. Glycan-binding profiles were used to identify autoreactive clones across B-cell subsets, specifically circulating marginal zone (MZ) B cells, for sorting and IGH sequencing. The locations, transcriptomes, and responses of tonsillar MZ B cells to different TH- cell subsets were determined by confocal microscopy, RNA-sequencing, and cocultures, respectively. RESULTS Autoreactive IgM coated erythrocytes and platelets from many CVID patients with AICs (CVID+AIC). On glycan arrays, CVID+AIC plasma IgM narrowly recognized erythrocytic i antigens and platelet i-related antigens and failed to bind hundreds of pathogen- and tumor-associated carbohydrates. Polyclonal i antigen-recognizing B-cell receptors were highly enriched among CVID+AIC circulating MZ B cells. Within tonsillar tissues, MZ B cells secreted copious IgM when activated by the combination of IL-10 and IL-21 or when cultured with IL-10/IL-21-secreting FOXP3-CD25hi T follicular helper (Tfh) cells. In lymph nodes from immunocompetent controls, MZ B cells, plentiful FOXP3+ regulatory T cells, and rare FOXP3-CD25+ cells that represented likely CD25hi Tfh cells all localized outside of germinal centers. In CVID+AIC lymph nodes, cellular positions were similar but CD25hi Tfh cells greatly outnumbered regulatory cells. CONCLUSIONS Our findings indicate that glycan-reactive IgM autoantibodies produced outside of germinal centers may contribute to the autoimmune pathogenesis of CVID.
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Affiliation(s)
- Carole Le Coz
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Infinity, Toulouse Institute for Infectious and Inflammatory Diseases, University of Toulouse, CNRS, Inserm, Toulouse, France
| | - Melissa Trofa
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Dorothy L Butler
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Md
| | - Samuel Yoon
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Tian Tian
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Whitney Reid
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Emylette Cruz Cabrera
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ainsley V C Knox
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Caroline Khanna
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kathleen E Sullivan
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jennifer Heimall
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa
| | - Patricia Takach
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, Pa
| | - Olajumoke O Fadugba
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, Pa
| | - Monica Lawrence
- Division of Asthma, Allergy and Immunology, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Soma Jyonouchi
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrew D Wells
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Spatial and Functional Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Steven Handler
- Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Karen B Zur
- Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Vinodh Pillai
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Hematopathology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jeffrey C Gildersleeve
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Md
| | - Neil Romberg
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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2
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Batarfi K, Liu Y, Nixon J, Webert KE, John MS, Karunakaran M, Alhomsi N, Park JJ, Heddle NM. A retrospective analysis of haemolytic reactions to intravenous immunoglobulin using data from the Transfusion-Transmitted Injuries Surveillance System (Ontario). Vox Sang 2023; 118:753-762. [PMID: 37592865 DOI: 10.1111/vox.13501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Haemolysis can occur following intravenous immunoglobulin (IVIG) infusion. Haemovigilance data were analysed using a novel approach for including two control groups with no haemolysis to IVIG. Objectives included a summary of all reactions to IVIG, rate estimates and analysis of haemolytic reactions including risk factors. MATERIALS AND METHODS Canadian haemovigilance data from Ontario (2013-2021), IVIG distribution and transfusion data from the blood supplier, and data from a large local transfusion registry were used. An 'other-reactions' control group included patients with IVIG reactions that were not haemolytic, and registry patients with no-reaction were the 'no-reaction controls'. Descriptive analysis and two logistic regression models for the different control groups were performed. RESULTS One thousand one hundred and seventy reactions were included. Most common were febrile non haemolytic (26.1%), minor allergic (24.5%) and IVIG headache (15.3%) followed by haemolytic 10.9% (128/1170). Haemolytic reaction rates decreased over time: rates since 2020 estimated between 1.5 and 2.9/1000 kg IVIG used. The regression model for other-reaction controls identified two risk factors for haemolysis: non-O blood group recipients compared with group O recipients (p value = 0.0106) and IVIG dose per 10 g increase (OR 1.359; 95% CI 1.225-1.506). The model using no-reaction controls gave similar results and also showed no pre-medication was associated with a higher risk of haemolysis (OR 29.084; 95% CI 1.989-425.312). CONCLUSION The frequency of haemolytic reactions has decreased over time. We confirmed non-O blood group recipients and IVIG dose as risk factors for haemolysis and raise the hypothesis that no pre-medication may increase the risk of haemolysis.
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Affiliation(s)
- Khalid Batarfi
- Transfusion Medicine Services, Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yang Liu
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joanne Nixon
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn E Webert
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Melanie St John
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Meera Karunakaran
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nour Alhomsi
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jane J Park
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Ottawa, Ontario, Canada
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3
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Cuesta H, El Menyawi I, Hubsch A, Hoefferer L, Mielke O, Gabriel S, Shebl A. Incidence and risk factors for intravenous immunoglobulin-related hemolysis: A systematic review of clinical trial and real-world populations. Transfusion 2022; 62:1894-1907. [PMID: 35916266 PMCID: PMC9545798 DOI: 10.1111/trf.17028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
Background Severe hemolysis rarely occurs in patients receiving intravenous immunoglobulin (IVIG) therapy. A systematic review was performed to assess the incidence of IVIG‐related hemolysis and the impact of patient and product risk factors. Study Design and Methods A systematic literature search for terms related to “IVIG products”, “hemolysis,” and “adverse events” was conducted in Embase for articles published between January 1, 2015, and May 31, 2021. Studies with no clinical datasets, no IVIG treatment, or where IVIG was used to treat hemolytic conditions were excluded. Of the 430 articles retrieved, 383 were excluded based on titles/abstracts and 14 were excluded after in‐depth review. Results In total, 33 articles were analyzed and separated into observational studies (n = 16), clinical trials (n = 8), and case reports (n = 9). The incidence proportion for IVIG‐related hemolysis ranged from 0% to 19% in observational studies and 0%–21% in clinical trials. A higher incidence of IVIG‐related hemolysis was consistently reported in patients with blood groups A and AB. Hemolysis occurred more frequently in patients treated with IVIG for some conditions such as Kawasaki disease; however, this may be confounded by the high dose of IVIG therapy. IVIG‐related hemolysis incidence was lower in studies using IVIG products citing manufacturing processes to reduce isoagglutinin levels than products that did not. Conclusion This analysis identified patient and product risk factors including blood group, IVIG dose, and IVIG manufacturing processes associated with elevated IVIG‐related hemolysis incidence.
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Affiliation(s)
| | | | | | | | | | | | - Amgad Shebl
- CSL Behring Innovation GmbH, Marburg, Germany
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4
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Wang Y, Khalenkov A, Scott DE. An optimized microplate-based method to evaluate complement-dependent hemolysis mediated by intravenous immunoglobulins (IVIG). Biologicals 2022; 78:1-9. [PMID: 35842374 DOI: 10.1016/j.biologicals.2022.06.005] [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: 12/26/2021] [Revised: 05/12/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Hemolytic reactions can cause serious complications after administration of Intravenous Immunoglobulin (IVIG), due to passive transfer of anti-A and anti-B IgG antibodies (isoagglutinins). A maximum allowable amount of isoagglutinins is established in the US and EU for licensed IVIG, as measured by a specified direct hemagglutination test (DHAT). Despite this limit, reports of hemolysis have increased over time, raising the question of how well the DHAT predicts clinically significant hemolysis. This study was undertaken to develop a microplate-based complement-dependent hemolysis assay (CDHA) that reproducibly measures functional hemolytic activity of IVIG, for assessment of IVIG products. An IVIG working reference reagent (NIBSC 14/160) was qualified as an assay control and for quantitation purposes. Hemolytic activities of 36 IVIG product lots encompassing seven brands and including 6 clinically hemolytic lots were measured. Hemolytic activity varied among IVIG product brands, and to a lesser extent, from lot-to-lot for individual brands. Correlation between the CDHA and DHAT was not robust which may reflect imprecision of the DHAT method or additional variables that influence complement-dependent hemolysis after opsonization. In conclusion, the CDHA provides a simple, specific, and sensitive tool for IVIG product characterization and investigation of hemolytic events by manufacturers, researchers, and regulatory authorities.
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Affiliation(s)
- Yonggang Wang
- Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA.
| | - Alexey Khalenkov
- Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Dorothy E Scott
- Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA.
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5
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IVMP+IVIG raises platelet counts faster than IVIG alone: results of a randomized, blinded trial in childhood ITP. Blood Adv 2021; 4:1492-1500. [PMID: 32282882 DOI: 10.1182/bloodadvances.2019001343] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/09/2020] [Indexed: 01/19/2023] Open
Abstract
Children with immune thrombocytopenia (ITP) rarely suffer from life-threatening bleeds (eg, intracranial hemorrhage). In such settings, the combination of IV methylprednisolone (IVMP) with IV immune globulin (IVIG) is used to rapidly increase platelet counts (PCs). However, there are no controlled data to support using combination therapy over IVIG alone. We conducted a randomized, double-blind, placebo-controlled study to evaluate the rapidity of the PC increment and associated adverse events (AEs) between 2 regimens: A (IV placebo) and B (IVMP 30 mg/kg), both given over 1 hour, followed in both cases by IVIG (Gamunex 10%) 1 g/kg over 2-3 hours in children 1-17 years old with primary ITP and PCs <20 × 109/L in whom physicians had decided to treat with IVIG. Thirty-two children (ages: median, 8 years; range, 1.2-17.5 years) with a mean baseline PC of 9.2 × 109/L participated. Eighteen were randomized to regimen A and 14 to regimen B. By 8 hours after initiating therapy, 55% of all children had a PC ≥20 × 109/L (no group difference). By 24 hours, mean PCs were 76.9 × 109/L (B) vs 55 × 109/L (A) (P = .06; P = .035 when adjusted for intergroup differences in patient ages). No patient experienced severe bleeding/unexpected severe AEs. There were statistically fewer IVIG-related headaches in the group receiving combination therapy (P = .046). Our findings show a rapid response to IVIG with/without steroids and provide evidence to support the use of IVMP+IVIG in life-threatening situations. This trial was registered at www.clinicaltrials.gov as #NCT00376077.
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6
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Tong TN, Blacquiere M, Sakac D, Burke-Murphy E, Yi Q, Callum J, Cserti-Gazdewich C, Parmar N, Shehata N, Pavenski K, Lau W, Lin Y, Lieberman L, Branch DR, Pendergrast J. The utility of a monocyte monolayer assay in the assessment of intravenous immunoglobulin-associated hemolysis. Transfusion 2020; 60:3010-3018. [PMID: 33091964 DOI: 10.1111/trf.16131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 09/10/2020] [Accepted: 09/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemolysis following the administration of intravenous immunoglobulin (IVIG) is an important adverse event (AE). While the monocyte monolayer assay (MMA) has been used to predict in vivo hemolysis when serologically incompatible blood may be transfused, it has also been shown to correlate with IVIG-associated hemolysis. In this study, the MMA was examined for its utility in assessing the risk of hemolysis after IVIG. STUDY DESIGN AND METHODS Forty-two non-blood group O patients receiving high-dose IVIG (≥2 g/kg) were examined using an autologous and allogeneic MMA. Hemolysis was defined by a drop in hemoglobin of ≥1 g/L, a positive direct antiglobulin test (DAT) and eluate, and a decrease in haptoglobin or increase in lactate dehydrogenase and/or reticulocytes. RESULTS Forty-two patients provided 50 assessable postinfusion samples, with hemolysis observed in 20 (40%) of cases. Autologous MMA using post-IVIG red blood cells significantly correlated with clinical outcomes when compared to allogeneic MMA (P = .0320 vs .5806, t test). No significant difference in receiver operating characteristics was observed when comparing autologous MMA testing against DAT for the diagnosis of IVIG-associated hemolysis. However, when using samples collected 5 to 10 days after receipt of high-dose IVIG, the autologous MMA had higher sensitivity than the DAT. CONCLUSION MMA testing with autologous monocytes collected 5 to 10 days after receipt of high-dose IVIG can be used for the diagnosis of IVIG-associated hemolysis and may be of particular value in cases in which the Day 5 to 10 DAT is negative.
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Affiliation(s)
- Tik Nga Tong
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada
| | - Megan Blacquiere
- Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada
| | - Darinka Sakac
- Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada
| | | | - Qilong Yi
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Nagina Parmar
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Nadine Shehata
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.,Canadian Blood Services, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Canadian Blood Services, Toronto, Ontario, Canada.,Department of Transfusion Medicine, Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Donald R Branch
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada.,Departments of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Pendergrast
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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7
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Yazdanbakhsh K, Zhong H. IVIg and hemolytic anemia risk: dump the anti-A/B already! Transfusion 2020; 60:1337-1339. [PMID: 32681818 DOI: 10.1111/trf.15939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Karina Yazdanbakhsh
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, USA
| | - Hui Zhong
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, USA
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8
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Wallenhorst C, Patel A, Shebl A, Hubsch A, Simon TL, Martinez C. Anti-A/B isoagglutinin reduction in an intravenous immunoglobulin product and risk of hemolytic anemia: a hospital-based cohort study. Transfusion 2020; 60:1381-1390. [PMID: 32488887 PMCID: PMC7496198 DOI: 10.1111/trf.15859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Intravenous immunoglobulins (IVIG) are derived from large human plasma pools. IVIG-associated hemolytic anemia (HA) is a known class effect, likely attributed to dose-dependent passive transfer of anti-A/B isoagglutinins. Two isoagglutinin reduction steps were implemented in the manufacturing process of Privigen (human 10% liquid IVIG): exclusion of high-anti-A-titer donors in 2013, replaced by specific immunoaffinity chromatography in 2015. We aim to estimate the clinical effectiveness of both measures. STUDY DESIGN AND METHODS Using the US hospital-based Premier Healthcare Database, three Privigen cohorts were generated based on calendar periods indicative of manufacturing changes: Period 1 (baseline) January 2008 to December 2012, Period 2 (high-anti-A-titer donor exclusion) October 2013 to December 2015, and Period 3 (immunoaffinity chromatography) October 2016 to April 2019. HA within a 10-day at-risk period after Privigen administrations was identified from review of patient record summaries. Incidence rate ratios (IRRs) were estimated from Poisson regression (Period 1 reference) adjusting for hospital setting, sex, age, Privigen indication, dose, and first use. RESULTS Crude incidence rates of HA were 1.49 per 10,000 person-days in Period 1 (38 HA, 9439 patients), 1.01 in Period 2 (20 HA, 7710 patients), and 0.14 in Period 3 (3 HA, 7759 patients). Adjusted IRR for HA in Period 2 was 0.71 (95% confidence interval [CI], 0.41-1.23), and in Period 3 was 0.10 (0.03-0.33) compared with Period 1. The IRR for HA in Period 3 compared with Period 2 was 0.14 (95% CI, 0.04-0.47). CONCLUSION Implementation of immunoaffinity chromatography in Privigen manufacturing resulted in a significant 90% reduction of HA risk. HA has become a rare event in association with Privigen use.
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Affiliation(s)
| | - Ami Patel
- CSL Behring LLC, King of Prussia, Pennsylvania, USA
| | | | | | | | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
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9
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Shebl A, Gabriel S, Van Dinther K, Hubsch A, Lawo JP, Hoefferer L, Welsh S. Isoagglutinin reduction in intravenous immunoglobulin (IgPro10, Privigen) by specific immunoaffinity chromatography reduces its reporting rates of hemolytic reactions: an analysis of spontaneous adverse event reports. Transfusion 2020; 60:1278-1286. [PMID: 32410287 PMCID: PMC7383922 DOI: 10.1111/trf.15846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hemolysis is an infrequent but recognized and potentially serious adverse effect of intravenous immunoglobulin (IVIG). Relatively elevated hemolysis reporting rates were seen with some IVIG products with high anti-A/B isoagglutinin content, among which IgPro10 (Privigen, CSL Behring). For IgPro10, two isoagglutinin reduction measures were successively implemented: 1) anti-A donor screening and 2) immunoaffinity chromatography (IAC; Ig IsoLo)-based isoagglutinin reduction step included in the production process. The aim of this analysis was to investigate the effects of these isoagglutinin reduction measures on the reporting rates of IgPro10 hemolysis worldwide. STUDY DESIGN AND METHODS Between February 2008 and December 2018, hemolysis reports from the CSL Behring Global Safety Database were analyzed in relationship to changes in IVIG IgPro10 production methods. Further analysis classified hemolysis reports by indication and blood group. RESULTS Median (minimum-maximum) anti-A/anti-B titers were 32 (8-64)/16 (8-32) at baseline, 32 (8-64)/16 (8-32) after donor screening, and 8 (8-32)/4 (2-8) after implementation of IAC. The reporting rate of hemolytic reactions per 1000 kg IgPro10 sold was 4.05 cases at baseline, 2.00 after donor screening, and 0.50 after implementation of IAC. In 2018, there were seven reports of hemolytic reactions; representing 0.18 cases per 1000 kg IgPro10 sold, with a reduction of 95.6% versus baseline. CONCLUSION Following implementation of the IAC isoagglutinin reduction step, spontaneous reports of hemolytic events with IgPro10 were significantly and consistently reduced versus IgPro10 without isoagglutinin reduction, offering patients a more favorable benefit-risk profile.
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Affiliation(s)
| | | | | | | | | | | | - Susan Welsh
- CSL Behring, King of Prussia, Pennsylvania, USA
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10
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Bürzle M, Hubsch A, Spiegl N, Roten T, Marques A, Martig L, Shebl A, Stadler D. Measurement of isoagglutinins in immunoglobulins for intravenous application by flow cytometry. Anal Biochem 2020; 591:113534. [PMID: 31821802 DOI: 10.1016/j.ab.2019.113534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/21/2019] [Accepted: 12/05/2019] [Indexed: 11/15/2022]
Abstract
Isoagglutinins present in intravenous immunoglobulin (IVIG) products have been linked to haemolysis. Therefore, accurately assessing isoagglutinin content in IVIG products is important. The standard European Pharmacopoeia (Ph.Eur.) direct assay is limited by low precision. Here, we describe the development of a fluorescence-activated cell sorting (FACS) method for assessing isoagglutinin levels. Serially diluted IVIG samples were incubated with red blood cells (RBCs), RBC-bound anti-A and anti-B antibodies were detected using a fluorescently-labelled antibody and the median fluorescence intensity of samples was assessed by FACS. Results were compared with the Ph.Eur. direct assay. The method was used to determine isoagglutinins in commercial products produced with and without isoagglutinin reduction steps. Assay precision, reported as the coefficient of variation, for the FACS method was 14% and 8% for anti-A and anti-B, respectively versus 33% and 20% with the Ph.Eur. direct assay. Application of the method on commercially available IVIGs revealed differences in isoagglutinin content between products produced with and without isoagglutinin reduction steps. This FACS assay allows for quantification of isoagglutinin concentrations in IVIGs with higher precision than the Ph.Eur. direct assay. Also the FACS assay confirms differences in isoagglutinin levels between IVIG products and the efficacy of isoagglutinin reduction measures.
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Affiliation(s)
- Marc Bürzle
- CSL Behring AG, Wankdorfstrasse 10, 3014, Bern, Switzerland.
| | | | - Nicole Spiegl
- CSL Behring AG, Wankdorfstrasse 10, 3014, Bern, Switzerland
| | - Thomas Roten
- CSL Behring AG, Wankdorfstrasse 10, 3014, Bern, Switzerland
| | | | - Lukas Martig
- CSL Behring AG, Wankdorfstrasse 10, 3014, Bern, Switzerland
| | - Amgad Shebl
- CSL Behring AG, Wankdorfstrasse 10, 3014, Bern, Switzerland
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11
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Cen SY, Branch DR. Isoagglutinin-reduced immunoglobulin retains efficacy in mouse models of immune thrombocytopenia and rheumatoid arthritis and is less likely to cause intravenous immunoglobulin-associated hemolysis. Transfusion 2019; 60:250-255. [PMID: 31837028 PMCID: PMC7496430 DOI: 10.1111/trf.15622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immunoglobulin therapy including intravenous immunoglobulin (IVIg) has been used as an effective treatment for autoimmune/inflammatory conditions with few side effects. However, high‐dose IVIg (1‐2 g/kg) has been recognized as a cause of hemolytic anemia in non–blood group O patients. Hemolysis when observed has been due to anti‐A/anti‐B isoagglutinins contained in the IVIg. Recently, an isoagglutinin‐reduced IVIg, whereby the anti‐A and anti‐B titers have been reduced by immunoaffinity chromatography, has been introduced; however, whether this new product is as efficacious as nonreduced immunoglobulin (Ig) or will result in less IVIg‐associated hemolysis has not been resolved. STUDY DESIGN AND METHODS We used in vitro phagocytosis by monocytes and proinflammatory/anti‐inflammatory macrophages, with isoagglutinin‐reduced and ‐nonreduced Ig opsonized group A1, B, and A1B red blood cells, to estimate clinical significance of the IgG isoagglutinins. We also used immune thrombocytopenia (ITP) and rheumatoid arthritis (RA) mouse models to examine the in vivo efficacy of isoagglutinin‐reduced versus ‐nonreduced Ig on the amelioration of the diseases. RESULTS In contrast to nonreduced Ig, phagocytosis was largely absent when isoagglutinin‐reduced Ig was used at a concentration equivalent to a patient receiving 2 g/kg. The in vivo efficacy of isoagglutinin‐reduced versus nonreduced Ig on the amelioration of experimental ITP and RA was similar, indicating no loss of efficacy due to the chromatographic removal of isoagglutinins. CONCLUSION Isoagglutinin‐reduced Ig should have efficacy similar to nonreduced Ig and result in less IVIg‐associated hemolysis.
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Affiliation(s)
- Selena Y Cen
- Center for Innovation, Canadian Blood Services, Toronto, Ontario, Canada
| | - Donald R Branch
- Center for Innovation, Canadian Blood Services, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Inpatient management strategies in a severe case of heparin-induced thrombocytopenia. Transfus Apher Sci 2019; 58:525-528. [DOI: 10.1016/j.transci.2019.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/26/2019] [Accepted: 06/03/2019] [Indexed: 01/25/2023]
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Taylor AS, Cooling L, Yamada C. ABO-associated antibody-mediated rejection following A2B-to-B renal transplantation and successful treatment with therapeutic plasma exchange. Transfusion 2019; 59:1883-1885. [PMID: 31050827 DOI: 10.1111/trf.15201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander S Taylor
- Transfusion Medicine/Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Laura Cooling
- Transfusion Medicine/Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Chisa Yamada
- Transfusion Medicine/Department of Pathology, University of Michigan, Ann Arbor, MI
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Lioger B, Maillot F, Ternant D, Passot C, Paintaud G, Bejan-Angoulvant T. Efficacy and Safety of Anti-D Immunoglobulins versus Intravenous Immunoglobulins for Immune Thrombocytopenia in Children: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Pediatr 2019; 204:225-233.e8. [PMID: 30314658 DOI: 10.1016/j.jpeds.2018.07.065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare the efficacy and safety of intravenous immunoglobulins (IVIG) and anti-D immunoglobulin (anti-D) in pediatric immune thrombocytopenia (ITP). STUDY DESIGN We conducted a systematic review and meta-analysis following PRISMA guidelines, including all randomized controlled trials that have assessed the efficacy and safety of anti-D and IVIG in children with ITP. We searched Medline, Embase, and Cochrane databases. Primary outcomes were the proportion of children achieving platelet count responses as defined in each study and bleeding response. Other safety outcomes included infusion reactions and hemolysis. RESULTS Eleven studies with 558 children were included. Anti-D was significantly inferior to IVIG at increasing platelet counts, both for thresholds of >20 × 109/L at 24-72 hours (response rate ratio for anti-D vs IVIG: 0.85, 95% CI 0.78-0.94) and >50 × 109/L at 24-72 hours (response rate ratio for anti-D vs IVIG: 0.75, 95% CI 0.61-0.92). Bleeding response was assessed in 4 studies, but some heterogeneity in reporting leads to unclear conclusion. General symptoms after anti-D infusion were less frequent than after IVIG (Peto OR 0.39, 95% CI 0.25-0.62). Hemolysis was more frequent after anti-D. The overall quality of the studies was low. CONCLUSIONS Compared with anti-D, IVIG led to a better response in terms of platelet count and may be preferred as a first-line treatment of ITP in children with acute hemorrhagic symptoms. However, the clinical significance of IVIG superiority on platelet count remains unclear.
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Affiliation(s)
- Bertrand Lioger
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Service de Médecine Interne, Tours, France.
| | - François Maillot
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; Université François-Rabelais de Tours, INSERM 1069, Tours, France
| | - David Ternant
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Christophe Passot
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Gilles Paintaud
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Theodora Bejan-Angoulvant
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Service de Pharmacologie Clinique, Tours, France
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Mallick R, Hubsch A, Barnes DG. Hemolytic adverse effects of intravenous immunoglobulin: modeling predicts risk reduction with anti‐A/B immunoaffinity chromatography and to a lesser extent with anti‐A donor screening. Transfusion 2018; 58:2752-2756. [DOI: 10.1111/trf.14918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/19/2018] [Accepted: 06/24/2018] [Indexed: 01/15/2023]
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Sharma A, Aryal D. Hemolysis induced cross-matching difficulty with intravenous immunoglobulin: a case report. J Med Case Rep 2018; 12:245. [PMID: 30173672 PMCID: PMC6120083 DOI: 10.1186/s13256-018-1774-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022] Open
Abstract
Background Intravenous immunoglobulin is one of the most common modalities of treatment for Guillain–Barré syndrome. Although minor complications are easily preventable with pre-medications, rare complications like hemolysis occur at unexpected times and carry risks of repeated transfusions. A complication like difficulties in cross-matching blood is an uncommon event and is often not anticipated. We present one such rare case. Case presentation A 56-year-old man of Asian origin had presented to our hospital with rapidly progressive weakness of bilateral upper and lower limbs over 4 days. Guillain–Barré syndrome was diagnosed by nerve conduction velocity testing and lumbar puncture examination. On the third day of admission in hospital he was intubated because of respiratory failure. Intravenous immunoglobulin at 0.4 mg/kg per day for 5 days was planned and started. Our patient was scheduled for tracheostomy on a routine basis anticipating prolonged requirement of ventilator support. As the blood was being arranged, the blood bank facilities informed us about difficulties in cross-matching of the blood. Repeated samples and attempts at cross-matching were futile. After reviewing the available literature and diagnosing a case of hemolysis, relevant tests were performed and they were positive. Conclusions Anti-A and anti-B antibody present in intravenous immunoglobulin preparations sensitize the red blood cells to hemolysis and this occurrence is often incriminated as a cause of cross-matching and sometimes blood grouping difficulty. Although a high dose of intravenous immunoglobulin or repeated courses are often cited as reasons for hemolysis, individual variability in responses is common and it is not surprising to see one like we had in our case.
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Affiliation(s)
- Achyut Sharma
- Department of Critical Care, Nepal Mediciti Hospital, Nakhkhu Patan, Karyabinayak, 44600, Nepal.
| | - Diptesh Aryal
- Department of Critical Care, Nepal Mediciti Hospital, Nakhkhu Patan, Karyabinayak, 44600, Nepal
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ABO zygosity, but not secretor or Fc receptor status, is a significant risk factor for IVIG-associated hemolysis. Blood 2018; 131:830-835. [PMID: 29305554 DOI: 10.1182/blood-2017-07-796151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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