Perceived health of patients with common variable immunodeficiency - a cluster analysis

Quantifying the Diagnostic Odyssey Burden Among Persons with Inborn Errors of Immunity

PURPOSE

Patients with inborn errors of immunity (IEI) have lifelong health complications including severe infections and physical impairments. Previous studies show that a patient's perception of their health is an important predictor of health outcomes. The purpose of this study was to understand factors related to patient reported health status.

METHODS

We used data from the Immunodeficiency Foundation (IDF) 2017 National Patient Survey and analyzed factors which correlated with the reported health status (RHS). Among a cohort of 1139 self-reported IEI patients, we identified age at the time of diagnosis, time gap between symptom onset and diagnosis, number of physicians seen, and whether the diagnosis was made in the first 5 years of life as significant. We used a two-tailed t-test, single-factor ANOVA, and Tukey-Kramer post-hoc test to assess statistical significance in the observed difference.

RESULTS

Patients who received a diagnosis before the age of 12 had a significantly better mean RHS (n = 207 pre-12a vs. n = 900 post-12a; p < 0.0001). Patients who received a diagnosis within 10 years of symptom onset showed improved mean RHS (n = 413 pre-10 vs. n = 524 post-10; p < 0.0001). Among patients who had symptom onset within the first 5 years of life, those who received a diagnosis had a significantly improved RHS (3.5 ± 0.92, n = 275 undiagnosed vs. 2.8 ± 0.94, n = 108 diagnosed; p < 0.0001). Finally, RHS was significantly impacted by number of physicians(n ≥ 4) seen prior to diagnosis (3.1 ± 0.96 vs. 3.4 ± 0.80, p < 0.0001).

CONCLUSION

These findings shed light upon critical factors which impact IEI patient RHS. Specifically, we find that efficient, rapid and early-life IEI identification should improve patient reported health and relevant outcomes. These improvements appear to be independent of the clinician specialty ultimately making the IEI diagnosis.

Health-related quality of life in patients with inborn errors of immunity: A systematic review and meta-analysis

BACKGROUND

Inborn Errors of Immunity (IEI) significantly affect patients' health-related quality of life (HRQOL), presenting greater challenges than those faced by the healthy population and other chronic disease sufferers. Current research lacks comprehensive integration of this critical issue.

OBJECTIVE

This study explores HRQOL in IEI patients, identifies impacting factors, and advocates for increased research focus on their quality of life.

METHODS

Following systematic review and meta-analysis guidelines, a search of Scopus and PubMed until November 15, 2023, yielded 1633 publications. We evaluated the literature, assessed study quality, and compared the HRQOL of IEI patients to that of healthy individuals and other chronic disease patients.

RESULTS

Of 90 articles and 10,971 IEI patients analyzed, study quality varied (nine good, 63 moderate, and 18 poor). The Short Form-36 (SF-36) and Pediatric Quality of Life Inventory generic core scales (PedsQL) were the primary generic instruments used among adults and children, respectively, with 12 studies each using the disease-specific instruments. Meta-analysis showed IEI patients have significantly lower scores in general health, physical and mental health, and social and emotional roles compared to healthy populations. We noted significant differences between self and proxy reports, indicating caregiver anxiety and perception disparities.

CONCLUSION

Despite limitations like small sample sizes and reliance on generic instruments, this research underscores the substantially lower HRQOL among IEI patients, emphasizing the need for a patient-centered, multidisciplinary approach to improve their life quality and calling for more focused attention on IEI patients and their caregivers' HRQOL.

Positive psychological profiles based on perceived health clustering in patients with cardiovascular disease: a longitudinal study

OBJECTIVES

Psychological well-being and sociodemographic factors have been associated with cardiovascular health. Positive psychological well-being research is limited in the literature; as such, this study aimed to investigate how patients with cardiovascular disease could be classified according to their perceived mental and physical health, and to identify positive psychological profiles based on this classification and test their stability over time.

DESIGN AND SETTING

Longitudinal study with patients from a public hospital located in Córdoba (Spain).

PARTICIPANTS

This study comprised 379 cardiovascular patients (87.3% men) tested at three measurement points.

OUTCOME MEASURES

Participants reported their sociodemographic variables (age, sex, educational level, employment and socioeconomic status) at phase 1, while their perceived health and variables relating to positive psychological well-being were tested at this and two subsequent time points (average interval time: 9 months).

RESULTS

The two-step cluster analysis classified participants into three groups according to their mental and physical health levels, p<0.001: high (n=76), moderate (n=113) and low (n=189) perceived health clusters. Low perceived health was the largest cluster, comprising almost half of patients. Clusters significantly differed according to sex, p=0.002, and socioeconomic level, p=0.004. The profile analysis indicated that participants in the high perceived health cluster showed high positive affect, positivity, life satisfaction, and self-efficacy in emotion regulation, and less negative affect and use of passive strategies over the three measurement points (95% CI, all ps<0.01). Moreover, psychological profile stability for each cluster was generally found over an 18-month period, all ps<0.05.

CONCLUSION

Cardiovascular patients may differ in terms of their perceived health and, accordingly, in terms of other relevant variables. Perceived health clusters generated varying and generally stable psychological profiles based on positive psychological well-being variables. Psychological interventions should be adapted to patients' requirements.

Bronchoalveolar Lavage Fluid Reflects a TH1-CD21low B-Cell Interaction in CVID-Related Interstitial Lung Disease

Background

About 20% of patients with common variable immunodeficiency (CVID) suffer from interstitial lung disease (ILD) as part of a systemic immune dysregulation. Current understanding suggests a role of B cells in the pathogenesis based on histology and increased levels of BAFF and IgM associated with active disease corroborated by several reports which demonstrate the successful use of rituximab in CVID-ILD. It is debated whether histological confirmation by biopsy or even video-assisted thoracoscopy is required and currently not investigated whether less invasive methods like a bronchoalveolar lavage (BAL) might provide an informative diagnostic tool.

Objective

To gain insight into potential immune mechanisms underlying granulomatous and lymphocytic interstitial lung disease (GLILD) and to define biomarkers for progressive ILD by characterizing the phenotype of B- and T-cell populations and cytokine profiles in BAL fluid (BALF) of CVID-ILD compared to sarcoidosis patients and healthy donors (HD).

Methods

Sixty-four CVID, six sarcoidosis, and 25 HD BALF samples were analyzed by flow cytometric profiling of B- and T-cells and for cytokines by ELISA and Multiplexing LASER Bead technology.

Results

Both sarcoidosis and CVID-ILD are characterized by a predominantly T-cell mediated lymphocytosis in the BALF. There is an increase in T follicular helper (TFH)-like memory and decrease of regulatory T cells in CVID-ILD BALF. This TFH-like cell subset is clearly skewed toward TH1 cells in CVID-ILD. In contrast to sarcoidosis, CVID-ILD BALF contains a higher percentage of B cells comprising mostly CD21low B cells, but less class-switched memory B cells. BALF analysis showed increased levels of APRIL, CXCL10, and IL-17.

Conclusion

Unlike in sarcoidosis, B cells are expanded in BALF of CVID-ILD patients. This is associated with an expansion of TFH- and TPH-like cells and an increase in APRIL potentially supporting B-cell survival and differentiation and proinflammatory cytokines reflecting not only the previously described TH1 profile seen in CVID patients with secondary immune dysregulation. Thus, the analysis of BALF might be of diagnostic value not only in the diagnosis of CVID-ILD, but also in the evaluation of the activity of the disease and in determining potential treatment targets confirming the prominent role of B-cell targeted strategies.

Variable immunodeficiency study: Evaluation of two European cohorts within a variety of clinical phenotypes

INTRODUCTION

Given the wide heterogeneity of common variable immunodeficiency (CVID), several groups have proposed clinical and immunological classifications to better define follow-up and prognostic algorithms. The present study aims to validate recent clinical and laboratory algorithms, based on different combinations of CVID biomarkers, to provide more personalized treatment and follow-up strategies.

METHODS

We analysed clinical and immunological features of 80 patients with suspected or diagnosed CVID, in two reference centres of Portugal and Spain. Clinical manifestations were categorized into clinical phenotyping proposed by Chapel et al. [1] that included cytopenia; polyclonal lymphocytic infiltration; unexplained enteropathy; and no disease-related complications.

RESULTS

76% of patients in our cohort entered one of the four categories of clinical phenotyping, without overlap (cytopenia; polyclonal lymphocytic infiltration; unexplained enteropathy; and no disease-related complications). The most prominent phenotype was "cytopenia" (40%) followed by "polyclonal lymphocytic infiltration" (19%). The remaining 24% patients of our cohort had overlap of 2 clinical phenotypes (cytopenia and unexplained enteropathy mainly). A delay of CVID diagnosis in more than 6 years presented 3.7-fold higher risk of developing lymphoproliferation and/or malignancy (p < 0.05), and was associated with increased CD8⁺CD45RO ⁺ T-lymphocytes (p < 0.05). An association between decreased switched-memory B cells with lymphoproliferation and malignancy was observed (p < 0.03 and p < 0.05, respectively). CD4 ⁺ T-lymphocytopenia correlated with autoimmune phenotype, with 30% prevalence (p < 0.05). HLA-DR7 expression was related to CVID onset in early life in our patients (13 vs 25 years), and DQ2.5 or DQ2.2 with unexplained enteropathy (p < 0.05).

CONCLUSIONS

The phenotypic and genetic study is crucial for an adequate clinical orientation of CVID patients. In these two independent cohorts of patients, classification based in clinical and laboratory algorithms, provides more personalized treatment and follow-up strategies.