IVIG adverse reactions: potential role of cytokines and vasoactive substances

BACKGROUND AND OBJECTIVES

A clinical study was conducted to determine the effect of IVIG infusion rates on adverse experiences (AE) and on serum levels of cytokines and vasoactive substances.

MATERIALS AND METHODS

Forty-two healthy volunteers were randomized into 3 groups with maximum IVIG infusion rates of 0.04, 0.06, and 0.08 ml/kg/min, and a final dose of 0.5 g IgG/kg body weight.

RESULTS

Adverse reactions were noted only at the highest infusion rate of 0.08 ml/kg/min, except in 1 subject infused at 0.06 ml/kg/min. There were significant increases in IL-6 (p = 0.011) and thromboxane B2 (p = 0.007) in AE subjects as compared to non-AE subjects.

CONCLUSION

IVIG-induced adverse reactions occur more often with rapid infusion rates and may be mediated by elevated levels of inflammatory cytokines and vasoactive substances.

Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty

A 2.8-year prospective multicenter trial was conducted to evaluate the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. A total of 441 inguinal hernias were repaired in 351 patients (326 male; 25 female). Two hundred twenty-six of the hernias were direct, 185 indirect, 4 femoral, 26 pantaloon, 90 bilateral, and 92 recurrent. Standardized data collection forms were used and submitted for centralized data analysis. For the hernioplasty, Cooper's ligament was exposed and an 8 cm x 12 cm x 1 mm GORE-TEX Soft Tissue Patch was stapled circumferentially to Cooper's ligament and the endoabdominal fascia. Patients were followed at 1 week, 6 months, 1 year, and then annually. Three-month intervals were used as needed. There was a mean follow-up of 447 days, with 21% of the total repairs followed for more than 2 years and 56% for more than a year. The overall follow-up rate was 95.5%. The operative and postoperative complication rates were 0.45% and 8%, respectively. There were 17 recurrent hernias (3.8%). The range of experience among the investigators was 13 to 168 hernioplasties. With the completion of 25 cases per investigator, the recurrence rate fell to 0.39%. Postoperative analgesia averaged a 24-hr supply of medication; 12.2% of patients required no analgesia. Convalescence averaged 5.4 days, and return to work averaged 7.7 days. This multicenter trial demonstrates that the ePTFE laparoscopic peritoneal onlay inguinal hernioplasty is a safe and dependable repair, especially after the initial learning curve is surmounted.

Virus removal or inactivation in hemoglobin solutions by ultrafiltration or detergent/solvent treatment

Two procedures to eliminate virus infectivity from hemoglobin solutions at ambient temperature were evaluated. In the first, virus removal was assessed during the ultrafiltration of hemoglobin solutions through a membrane with a nominal molecular weight cut-off of 100,000 Daltons. The results of this study demonstrated that less than 0.1% of any virus originally spiked into the solution was detectable in the ultrafiltrate. In the second procedure the inactivation of viruses in hemoglobin solutions incubated with tri(n-butyl)phosphate mixed with sodium cholate was studied. Greater than 99% of each of the enveloped viruses tested was inactivated during the first 15 minutes of incubation with greater than 10(5) plaque forming units/ml of each being inactivated after one to six hours. No inactivation of the non-enveloped poliovirus was effected by this treatment. The data imply that both ultrafiltration and detergent/solvent incubation may reduce virus infectivity in hemoglobin solutions, but neither method yields a completely virus free product.

Virus inactivation in hemoglobin solutions by heat

To determine the feasibility of heat treating hemoglobin solutions to inactivate viruses, we performed experiments on the thermal stability of this protein and found that the structure and function of deoxyhemoglobin are well preserved during incubation at 60 degrees C for 10 hours at a pH of 7.5. Model viruses and the human immunodeficiency virus were rapidly inactivated under these conditions. The results imply that incubation at 60 degrees C is a practical method for inactivating viruses in hemoglobin solutions.

Enzyme immunoassay for the quantitation of immunoglobulin M class antibodies to Salmonella minnesota R595 and Escherichia coli J5 lipopolysaccharides

The level of human immunoglobulin (IgM) in plasma specific for the lipopolysaccharide of Salmonella minnesota R595 (R595 LPS) and Escherichia coli J5 (J5 LPS) was quantitated by an enzyme immunoassay (EIA) in which purified antigen is adsorbed directly onto polystyrene-acrylic copolymer cuvettes. Highly purified anti-J5 and R595 LPS specific IgM prepared by ion-exchange resin, gel filtration, and affinity resin chromatography were used as standards. The levels of specific IgM were determined in 200 plasma samples obtained from normal donors. Anti-R595 IgM levels varied from less than 30 micrograms/ml (91%), from 30 to 100 micrograms/ml (8.5%), and greater than 100 micrograms/ml (0.5%). Anti-J5 IgM levels in 68% of the donor plasmas were less than or equal to 5 micrograms/ml. The levels in 30.5% of the donor plasmas ranged from 6 to 100 micrograms/ml; the remaining 1.5% had greater than 100 micrograms/ml anti-J5 IgM. Specific IgM levels in four lots of normal pooled plasma each consisting of about 10,000 L averaged 12.7 micrograms/ml and 13.3 micrograms/ml for R595 and J5, respectively. The assay was modified to quantitate rabbit plasma as well. For this purpose, the EIA has been performed on microtiter plates, and the core LPS was fixed onto the wells by chemical treatment with glutaraldehyde which results in higher stability and retention of the antigen in the wells. Specificity of the EIA was demonstrated by the absence of significant cross reactivity between R595 IgM and J5 LPS and between J5 IgM and R595 LPS, furthermore, we only observed partial adsorption (approximately 25%-33%) of the R595 and J5 IgM by Pseudomonas aeruginosa LPS, a wild type endotoxin. The described quantitative assay is useful for both scientific studies and clinical investigations.

Enzyme immunoassay for the quantitation of human immunoglobulin G specific for the glycolipid of Enterobacteriaceae

An enzyme immunoassay (EIA) is reported that quantitates human immunoglobulin (Ig)G specific for the glycolipid (Re-GL) of Salmonella minnesota Re 595. Re-GL was adsorbed to polystyrene microcuvettes, and 100 microliters of appropriately diluted lots of human plasma or affinity-purified rabbit anti-Re-Gl IgG was added to the cuvettes. The cuvettes were incubated, washed, and then reacted with Staphylococcus aureus protein A-peroxidase. After a final wash the substrate 2,2'-azino-di(3-ethylbenzthiazoline)sulfonic acid (ABTS) was added to yield a blue-green color with a maximum absorption at 405 nm. Using the affinity-purified rabbit anti-Re-IgG as standard, it was possible to quantitate specific levels of anti-Re-GL. The EIA was rapid (2 hr), with an absolute sensitivity of 5 ng of specific anti-Re-GL IgG and an interassay coefficient of variation of 24%. On a unit-mass basis, rabbit anti-Re-GL IgG had 10-fold greater activity than comparable affinity-purified human anti-Re-GL IgG from normal donor plasma. When a rabbit standard was used, the mean level of specific anti-Re-GL IgG in lots of pooled human plasma, which consisted of 18,330 liters, was 1.1 +/- 0.28 micrograms/ml. Of 237 individual donors tested, 24 (10%) had levels of anti-Re-GL IgG that were 10-fold or greater than the mean of 1.1 micrograms/ml. The EIA provided a rapid, reproducible method for accurate quantitation of specific anti-Re-GL IgG in the screening of large volumes of human plasma.

Functional alpha 1 protease inhibitor produced by a human hepatoma cell line

Alpha 1 protease inhibitor antigen was identified in the culture medium of the human ascites hepatoma cell line SK-HEP-1. Trypsin inhibitory activity and alpha 1 Pl antigen accumulated in serum-free medium concomitantly over a period of several days. Radioactive alpha 1 Pl antigen was detected in conditioned medium from cultures supplemented with 35S-L-methionine, indicating a synthesis and release of the protein. Alpha 1 Pl antigen in conditioned medium appeared to be antigenically identical to that in human plasma, and the newly synthesized (radiolabeled) antigen co-migrated with plasma, alpha 1 Pl after immunoelectrophoresis or SDS-polyacrylamide gel electrophoresis. Moreover, evidence is presented that the synthesized inhibitor exhibits functional activity, since the 35S-labeled alpha 1 Pl in conditioned medium complexes with trypsin. We conclude that SK-HEP-1 cells in culture produce functionally active alpha 1 Pl which may be identical to that in plasma.

Isolation of alpha 1-protease inhibitor from human normal and malignant ovarian tissue

Proteolytic enzymes are associated with normal and neoplastic tissues. Therefore protease inhibitors might also be involved in the control of cell function. alpha 1-protease antigen and antitryptic activity have been found in normal and neoplastic human ovarian homogenate. The inhibitor has been localized to ovarian stromal cells or tumor cells by immunoperoxidase staining. The protein was purified to apparent homogeneity as judged by alkaline gel and sodium dodecyl sulfate (SDS) gel electrophoresis. Immunochemical studies revealed antigenic similarity of plasma alpha 1-protease inhibitor by double immunodiffusion and similar mobility on immunoelectrophoresis and two-dimensional electroimmunodiffusion. The molecular weight was similar to that described for plasma alpha 1-protease inhibitor: 60,000 by gel filtration and 53,500 by SDS electrophoresis. Furthermore, the phenotypic pattern as determined by acid starch gel electrophoresis and immunoprecipitation was PiMM, which is the predominant genetic variant in normal plasma alpha 1-protease inhibitor. An inhibitor ws isolated and purified from an ovarian carcinoma that exhibited functional, immunochemical, and physical similarity to the normal ovarian alpha 1-protease inhibitor. alpha 1-protease inhibitor from normal and malignant ovaries competitively inhibited bovine pancreatic trypsin at incubation times of 5 min at 30 degrees C. Inhibition constant (Ki) values were calculated at 0.67 and 0.51 inhibitory units, respectively. The alpha 1-protease inhibitor in malignant cells may be a factor in the control of proliferation in this tissue. Since ovulation is in part a proteolytic event, the alpha 1-protease inhibitor in ovarian cells may play a role in the control of this specialized tissue. Persistance of this protein in malignant ovarian tissue may be a vestige of its differentiated origin.

Activation of bovine factor VII by hageman factor fragments

During the early events of coagulation of human blood by the intrinsic pathway, factor XII is activated to a form which can activate factor XI, and is proteolytically fragmented to smaller species (30,000 daltons and 70,000 daltons) which have lost most of the ability to activate factor XI but which can activate prekallikrein rapidly. The effect of these fragments on factor VII was studied. It was found that these Hageman factor fragments promoted rapid proteolysis of one-chain factor VII to a more active two-chain form. The amino-terminal sequences of the chains of activated factor VII were found to be Ala-Asx-Gly- and Ile-Val-Gly-, the same as were earlier observed after activation of factor VII by activated factor X. This finding indicates that initiation of coagulation by the intrinsic pathway also primes the extrinsic pathway.

Potentiation of the function of Hageman factor fragments by high molecular weight kininogen

Patients lacking high molecular weight (HMW) kininogen have profound abnormalities of the Hageman factor-dependent pathways of coagulation, kinin formation, and fibrinolysis. The ability of HMW kininogen to potentiate the Hageman factor fragments (HFf) activation of prekallikrein and Factor XI in plasma was studied. HFf only partially converted Factor XI to XIa and prekallikrein to kallikrein in plasma deficient in HMW kininogen (Williams trait), while enhanced activation of Factor XI and prekallikrein by HFf resulted after reconstitution with HMW kininogen. In a system using highly purified components, HMW kininogen increased the initial rate of prekallikrein activation whether the kallikrein formed was assayed by arginine esterase activity or kininforming ability. The potentiation of prekallikrein activation occurred over a 12-fold range of enzyme (HFf) concentration and was nonhyperbolic with respect to substrate (prekallikrein). HMW kininogen exerted its effect even in the absence of prekallikrein since the hydrolysis of acetylglycyl-lysine methyl ester by HFf was increased by HMW kininogen. These results suggest that one of the functions of HMW kininogen is to augment the catalytic action of HFf.

Williams trait. Human kininogen deficiency with diminished levels of plasminogen proactivator and prekallikrein associated with abnormalities of the Hageman factor-dependent pathways

An asymptomatic woman (Ms. Williams) was found to have a severe abnormality in the surface-activated intrinsic coagulation, fibrinolytic, and kinin-generating pathways. Assays for known coagulation factors were nromal while Fletcher factor (pre-kallikrein) was 45%, insufficient to account for the observed markedly prolonged partial thromboplastin time. Plasminogen proactivator was present at 20% of normal levels and addition of highly purified plasminogen proactivator containing 10% plasminogen activator partially corrected the coagulation and fibrinolytic abnormalities but not the kinin-generating defect. This effect was due to its plasminogen activator content. In addition, Williams trait plasma failed to convert prekallilrein to lakkilrein or release kinin upon incubation with kaolin. Kininogen antigen was undetectable. When normal plasma was fractionated to identify the factor that corrects all the abnormalities in Williams trait plasma, the Williams factor was identified as a form of kininogen by its behavior on ion exchange chromatography, gel filtration, disc gel electrophoresis, and elution from an anti-low molecular weight kininogen immunoadsorbent. High molecular weight kininogen as well as a subfraction of low molecular weight kininogen, possessed this corrective activity while the bulk of low molecular weight kininogen functioned only as a kallikrein substrate. Kininogen therefore is a critical factor required for the functioning of Hageman factor-dependent coagulation and fibrinolysis and for the activation of prekallikrein.

Immunochemical studies of plasma kallikrein

A monospecific antibody against human plasma kallikrein has been prepared in rabbits with kallikrein further purified to remove gamma globulins. The antisera produced contained antikallikrein and also anti-IgG, in spite of only 8% contamination of kallikrein preparation with IgG. The latter antibody was removed by adsorption of antisera with either Fletcher factor-deficient plasma or with purified IgG. Both kallikrein and prekallikrein (in plasma) cross-react with the antibody with no apparent difference between the precipitation arcs developed during immunoelectrophoresis and no significant difference in reactivity when quantified by radial immunodiffusion. Kallikrein antibody partially inhibits the esterolytic and fully inhibits the proteolytic activity of kallikrein. In addition, the antibody inhibits the activation of prekallikrein, as measured by esterase or kinin release. The magnitude of the inhibition is related to the molecular weight of the activator used. Thus, for the four activators tested, the greatest inhibition is observed with kaolin and factor XII(A), while large activator and the low molecular weight prekallikrein activators are less inhibited. With the kallikrein antibody, the incubation of kallikrein with either plasma or partially purified C1 esterase inactivator results in a new precipitin arc, as detected by immunoelectrophoresis. This finding provides physical evidence for the interaction of the enzyme and inhibitor. No new arc could be demonstrated between kallikrein and alpha(2)-macroglobulin, or alpha(1)-antitrypsin, although the concentration of free kallikrein antigen decreases after interaction with the former inhibitor. By radial immunodiffusion, plasma from healthy individuals contained 103+/-13 mug/ml prekallikrein antigen. Although in mild liver disease, functional and immunologic kallikrein are proportionally depressed, the levels of prekallikrein antigen in plasma samples from patients with severe liver disease remains 40% of normal, while the functional kallikrein activity was about 8%. These observations suggest that the livers of these patients have synthesized a proenzyme that cannot be converted to active kallikrein.