Effect of various treatments of gamma-globulin (IgG) for achieving intravenous tolerance on the capacity to interact with human monocyte Fc receptors. A comparative study

Limited Innovations After More Than 65 Years of Immunoglobulin Replacement Therapy: Potential of IgA- and IgM-Enriched Formulations to Prevent Bacterial Respiratory Tract Infections

Patients with primary immunoglobulin deficiency have lower immunoglobulin levels or decreased immunoglobulin function, which makes these patients more susceptible to bacterial infection. Most prevalent are the selective IgA deficiencies (~1:3,000), followed by common variable immune deficiency (~1:25,000). Agammaglobulinemia is less common (~1:400,000) and is characterized by very low or no immunoglobulin production resulting in a more severe disease phenotype. Therapy for patients with agammaglobulinemia mainly relies on prophylactic antibiotics and the use of IgG replacement therapy, which successfully reduces the frequency of invasive bacterial infections. Currently used immunoglobulin preparations contain only IgG. As a result, concurrent IgA and IgM deficiency persist in a large proportion of agammaglobulinemia patients. Especially patients with IgM deficiency remain at risk for recurrent infections at mucosal surfaces, which includes the respiratory tract. IgA and IgM have multiple functions in the protection against bacterial infections at the mucosal surface. Because of their multimeric structure, both IgA and IgM are able to agglutinate bacteria efficiently. Agglutination allows for entrapment of bacteria in mucus that increases clearance from the respiratory tract. IgA is also important for blocking bacterial adhesion by interfering with bacterial adhesion receptors. IgM in its place is very well capable of activating complement, therefore, it is thought to be important in complement-mediated protection at the mucosal surface. The purpose of this Mini Review is to highlight the latest advances regarding IgA- and IgM-enriched immunoglobulin replacement therapy. We describe the different IgA- and IgM-enriched IgG formulations, their possible modes of action and potential to protect against respiratory tract infections in patients with primary immunoglobulin deficiencies.

Immunoglobulin Resistance in Kawasaki Disease

Background: The aim of this study was to identify risk factors for immunoglobulin resistance, including clinical symptoms such as arthritis and the pH of intravenous immunoglobulin. Methods: The data of children with Kawasaki disease who had received immunoglobulin were evaluated. Data regarding the brand of immunoglobulin administered were abstracted from the pharmacy records. Results: Eighty consecutive children with Kawasaki disease were evaluated (Mdn_age=28 months, 66% male). The prevalence of immunoglobulin resistance was 30%. Arthritis was a presenting symptom in the acute phase of Kawasaki disease in 8% (6/80, all male) and was seen in significant association with immunoglobulin resistance in comparison to those without arthritis (16.7% vs. 0.2%, p=0.008). Next, the immunoglobulin brand types were divided into two groups: the relatively high pH group (n=16), including Carimune (pH 6.6±0.2), and the low pH group (n=63), including Gamunex (pH 4-4.5) or Privigen (pH 4.6-5). Overall, no significant difference in immunoglobulin responsiveness was found between the low pH and the high pH groups (73% vs. 56%, p=0.193), although the low pH group showed a trend toward a larger decrease in erythrocyte sedimentation rate (p=0.048), lower steroid use (p=0.054), and lower coronary involvement (p=0.08) than those in the high pH group. Conclusions: Children presenting with arthritis in the acute phase of Kawasaki disease may be at risk for immunoglobulin resistance.

Comparative effectiveness of intravenous immunoglobulin for children with Kawasaki disease: a nationwide cohort study

Introduction

Different immunoglobulin manufacturing processes may influence its effectiveness for Kawasaki disease. However, nationwide studies with longitudinal follow-up are still lacking. The aim of this study was to evaluate the comparative effectiveness of immunoglobulin preparations from a nationwide perspective.

Materials and Methods

This is a nationwide retrospective cohort study with a new user design. Data came from the National Health Insurance Research Database of Taiwan. From 1997 to 2008, children under 2 years old who received immunoglobulin therapy for the first time under the main diagnosis of Kawasaki disease were enrolled. The manufacturing processes were divided into β-propiolactonation, acidification and those containing IgA. The endpoints were immunoglobulin non-responsiveness, acute aneurysm, prolonged use of anti-platelets or anti-coagulants, and recurrence.

Results

In total, 3830 children were enrolled. β-propiolactonation had a relative risk of 1.45 (95% CI 1.08∼1.94) of immunoglobulin non-responsiveness, however, the relative risks for acidification and containing IgA were non-significant. For acute aneurysms, acidification had a relative risk of 1.49 (95% CI 1.17∼1.90), however the relative risks for β-propiolactonation and containing IgA were non-significant. For prolonged use of anti-platelets or anti-coagulants, β-propiolactonation had a relative risk of 1.44 (95% CI 1.18∼1.76), and acidification protected against them both with a relative risk of 0.82 (95% CI 0.69∼0.97), whereas the relative risk for containing IgA was non-significant. For recurrence, all three factors were non-significant.

Conclusions

The effectiveness of immunoglobulin may differ among different manufacturing processes. β-propiolactonation had a higher risk of treatment failure and prolonged use of anti-platelets or anti-coagulants. Acidification may increase the risk of acute coronary aneurysms.

Clinical responses of patients with Kawasaki disease to different brands of intravenous immunoglobulin

OBJECTIVE

To determine whether different brands of intravenous immunoglobulin (IVIG) administered to children with Kawasaki disease (KD) result in different outcomes.

STUDY DESIGN

We analyzed children with KD and divided them into 4 groups according to the brand of IVIG. A coronary artery abnormality (CAA) was defined as having a lumen diameter (inner border to inner border) of > or =3 mm in KD cases <5 years old and > or =4 mm in cases > or =5 years old, and giant aneurysm was defined as a lumen diameter > or =8 mm. Patients were considered nonresponsive to IVIG therapy if fever persisted longer than 2 days after completion of treatment and needed retreatment with IVIG.

RESULTS

We collected 437 cases, 29 (6.6%) were nonresponsive, 17 (3.9%) had CAA at convalescence, and 3 (0.7%) had giant aneurysm, 2 of whom had development of myocardial infarcts. Patients receiving Brand C IVIG, prepared with beta-propiolactone, had higher rates (10%, 9/93, P = .01) of CAA at convalescence and nonresponsiveness (13%, 12/93, P = .001); giant aneurysm occurred in 3/93 (3%) receiving Brand C IVIG and in 0/344 who received the other 3 brands (P = .008).

CONCLUSIONS

IVIG, prepared with beta-propiolactone, was most significantly associated with nonresponsiveness, CAA at convalescence, and giant aneurysm. Physicians should be cautious when using IVIG prepared with beta-propiolactone or enzyme digestion to treat KD.

Anticomplementary activity of equine whole IgG antivenoms: comparison of three fractionation protocols

Early adverse reactions occur in a number of patients treated with heterologous antivenoms and have been associated with anticomplementary activity (ACA). In order to reduce the ACA of equine whole IgG antivenoms produced by caprylic acid fractionation, three different fractionation protocols were compared: (a) routine caprylic acid fractionation; (b) caprylic acid fractionation followed by beta-propiolactone treatment; and (c) caprylic acid fractionation followed by ion-exchange chromatography using a quaternary ammonium membrane. The three protocols yielded products with similar physicochemical characteristics and anti-Bothrops asper venom antibody titers, except that ion-exchange purified antivenom had a lower protein concentration. Antivenoms fractionated by using beta-propiolactone or filtration through quaternary ammonium membrane had a significantly reduced in vitro ACA. A preparation of caprylic acid-fractionated antivenom was heated in order to induce the formation of protein aggregates; however, its ACA was similar to non-heated antivenom. None of the antivenoms affected the hemolytic activity of serum complement in rabbits after a bolus intravenous administration. It is concluded that (a) beta-propiolactone and quaternary ammonium membranes significantly reduce in vitro ACA of caprylic acid-fractionated equine antivenom, and (b) the validity of in vitro ACA as a predictor of EAR needs to be reexamined in clinical and experimental studies, since it may not adequately predict in vivo complement activation by antivenoms.

Comparison of IgG preparations by a turbidimetric assay of opsonizing capacity

A convenient turbidimetric phagocytosis assay was applied for the functional comparison of various intravenous IgG preparations. Staphylococcus aureus (Oxford) was opsonized by the immunoglobulin samples in the presence of an IgG deficient serum as a source of complement. The opsonized bacteria were subjected to phagocytosis by neutrophil granulocytes isolated from healthy adults. The time course of phagocytosis was monitored by the decrease of light absorbance at 400 nm. Changes in light absorbance during a 15 min period of opsonophagocytosis (delta E(400)) were expressed as a percentage of delta E(400) obtained by a reference IgG preparation. The opsonizing effect of five commercially available i.v. IgG preparations was compared. Three different preparations containing whole, non-modified IgG molecules had a comparable opsonizing effect while a further one prepared by propiolacton modification displayed a reduced activity (52%) of the reference preparation, taken as 100%. A preparation consisting of IgG molecules without an Fc-region proved to be practically ineffective (8.7%).

Polyvalent immunoglobulin for intravenous use interferes with cell proliferation in vitro

Intravenous immunoglobulin is used to an increasing extent in various immune-mediated diseases, but its mechanism(s) of action in vivo is incompletely understood. Previous studies have shown that intravenous immunoglobulin may interfere with autoantibodies and their production by B cells and also inhibit Fc-mediated antibody-dependent cytotoxicity. Here we describe a novel effect of intravenous immunoglobulin on proliferation of in vitro activated peripheral blood lymphocytes and autonomously growing cell lines of various origin. Independently of whether proliferation was autonomous or induced by antigen-specific or antigen-nonspecific reagents, proliferation was inhibited in a dose-dependent fashion, as measured by reduced 3H-thymidine and BrdU uptake and cell counting. The effect was not due to cytotoxic effects of intravenous immunoglobulin and was reversible after removing the intravenous immunoglobulin by washing. The IgG levels required for this inhibition of proliferation are supraphysiological but are reached in vivo during treatment with intravenous immunoglobulin.

IgG2b-dependent down regulation of the LPS-induced PFC-response and its blockade by Fc gamma 2bR protein

Fc gamma receptor (Fc gamma R)-dependent immunoregulation by murine heat-aggregated (HAgg) IgG subclasses on the bacterial lipopolysaccharide (LPS)-induced plaque forming cell (PFC) response to trinitrophenylated sheep red blood cell (TNP-SRBC) antigen and the competitive effect by Fc gamma 2bR-protein on the down regulation by HAgg-IgG2b were studied in murine T-cell-deprived spleen cell cultures. HAgg-IgG1 and HAgg-IgG3 enhanced the PFC response, but HAgg-IgG2b strongly suppressed the LPS-induced PFC response. HAgg-IgG1 could not compete with the suppressive effect of HAgg-IgG2b. The HAgg-IgG2b seemed to act on both macrophages (M phi) and B-cells, because the cell cultures that had been reconstituted with HAgg-IgG2b-pretreated M phi and untreated B-cells and vice versa showed poor PFC responses. The suppression induced by HAgg-IgG2b on the LPS-induced PFC response in the T-cell-deprived cultures was abolished by the addition of phospholipase C (PLC)-treated Fc gamma 2bR protein at the early stage of the culture. The mechanisms by which HAgg-IgG2b suppress the LPS-induced PFC response and PLC-treated Fc gamma 2bR protein restores this response were discussed.

Monomeric and dimeric IgG1 as probes for assessing high-affinity and low-affinity receptors for IgG on human monocyte-derived macrophages and on activated macrophages

From a panel of IgG1 myeloma proteins, only one was found to interact with human monocyte FcR in a manner similar to that of polyclonal IgG. This protein was used in binding studies involving human macrophage Fc receptors. A monomeric fraction depleted of dimeric and polymeric IgG1 was crosslinked with bis-diazonium benzidine, and a fraction highly enriched in cross linked IgG1 dimers was radiolabeled. Labeled monomeric and dimeric IgG were allowed to interact with monocytes that had matured to macrophages in vitro. The association with macrophages at 4 degrees C, in the presence of cytochalasin B, reached a plateau after 6 hr. The dissociation induced by excess unlabeled IgG followed similar kinetics as the association, but 20-30% of the bound IgG could not be dissociated. Under equilibrium conditions, evidence for a single FcR population binding monomeric IgG was obtained, the Kd being in the range of 12-42 nM. In contrast, the binding of dimeric IgG was more consistent with a model assuming two populations of binding sites when appropriate curve-fitting calculations were applied. The high-affinity FcR population had a Kd in the range of 0.8-3.5 nM, whereas the Kd of the low-affinity FcR population was in the range of 28-85 nM. When macrophages had been pre-treated with recombinant interferon-gamma, the expression of high-affinity sites was increased by a factor of 1.5-3, but the number of low-affinity sites was not augmented. Cytofluorographic analyses confirmed the increased expression of high-affinity FcR, binding fluoresceinating murine IgG2a. The expression of CD16, a low-affinity FcR expressed on neutrophils, NK cells and macrophages, as well as the expression of the complement receptor type III was little influenced by the rIFN-gamma pretreatment.

Safety aspects of intravenous immunoglobulins

Seven commercially available intravenous immunoglobulins (IVIG) preparations, a gamma globulin prepared by ethanol fractionation, and an experimental IgG isolated by a chromatographic procedure were compared in several tests. Split products were present in preparations manufactured by procedures involving protease treatment and in a sulphitolysed IgG. The same preparations and another chemically modified product displayed a loss in their capacity to bind staphylococcal protein A. None of the preparations exerted a high anticomplementary activity using concentrated human serum as a complement source. No strict correlation between aggregate content and anticomplementary activity could be established. None of the commercial IVIG preparations tested displayed a sizeable hypotensive action as assessed by a rat model involving potentiation of bradykinin action by an angiotensin convertase inhibitor. The chromatographically purified IgG and an intramuscular IgG prepared by Rivanol fractionation contained high endogenous protease and prekallikrein activator (PKA) activity, respectively and both were found markedly hypotensive. Neither endogenous protease nor PKA activity was detected in the Cohngammaglobulin fraction. However, it was very strongly hypotensive even without any previous blocking of angiotensin convertase. Our data support the view that immunoglobulin preparations may affect blood pressure without inducing bradykinin generation.

Immunoglobulin therapy in bone marrow transplantation

Following ablative treatment with supralethal doses of chemotherapy and total body irradiation, patients demonstrate multiple immunologic deficiencies after bone marrow transplantation. Immune function usually recovers and the risk of infection decreases within six to 12 months. However, patients in whom chronic graft-versus-host disease (GVHD) develops have persisting B and T cell abnormalities, and in vivo and in vitro studies show impaired immunoglobulin regulation and function despite normal levels of serum immunoglobulin G. This review summarizes 12 published clinical trials of immunoglobulin therapy to correct immunodeficiency and prevent infection after marrow grafting. In five controlled studies, cytomegalovirus infection developed in a total of 52 of 172 (30 percent) immunoglobulin recipients and 71 of 165 (43 percent) control patients not given globulin. In four controlled trials, interstitial pneumonia developed in a total of 21 of 127 (17 percent) immunoglobulin recipients and 40 of 94 (43 percent) control patients. Three randomized trials reported a reduced rate of GVHD or post-engraftment septicemia in immunoglobulin recipients. However, methods of immunoglobulin preparation, antibody titer, and dose and schedule of prophylaxis varied widely in these studies, as did other critical patient, transplant regimen, and supportive care factors. Accordingly, data should be interpreted with caution. Ongoing controlled clinical trials will further define the proper role of immunoglobulin therapy in bone marrow transplantation.

The capacity of various types of immunoglobulin for intravenous use to interact with Fc receptors of human monocytes and macrophages

The capacity of immunoglobulin for intravenous application (IgG-IV) to interact with Fc receptors of human monocytes and macrophages was tested by quantifying the inhibition of phagocytosis of IgG-sensitized erythrocytes. To this end a spectrometric phagocytosis test has been used. When compared with IgG for i.m. use (IgG-IM), all IgG-IV had reduced activity. This reduction was related, in part, to the reduced amount of IgG dimers and polymers in IgG-IV. On a weight basis dimeric IgG and polymeric IgG exerted 6-fold and 14-fold higher activity, respectively, than monomeric IgG. When this difference was corrected for, chemically modified IgG-IV still had significantly reduced inhibitory activity; DEAE-Sephadex-treated IgG and acid-treated IgG had an activity similar to IgG-IM, and PEG-treated IgG showed a slightly reduced activity. Pepsin-treated IgG was greater than 100-fold less active than IgG-IM. The reactivity of IgG-IV with monocyte and macrophage Fc receptors was closely correlated. The most conspicuous differences found were related to the concentration at which IgG was used. Thus, beta-propiolactone-treated IgG and plasmin-treated IgG were found to have significantly reduced activity at concentrations greater than 20 micrograms/ml, but almost normal activity when used at lower concentrations.