[Clinical effect of gamma globulin pulse therapy for abdominal Henoch-Schönlein purpura in children]

OBJECTIVE

To study the clinical effect of high-dose gamma globulin pulse therapy for abdominal Henoch-Schönlein purpura (HSP).

METHODS

Thirty-three children with abdominal HSP were randomly assigned to dexamethasone group (15 children) and gamma globulin group (18 children). The children in the dexamethasone group were treated with dexamethasone and conventional treatment, and those in the gamma globulin group were treated with high-dose gamma globulin pulse therapy in addition to the conventional treatment. Clinical outcome and recurrence rate were observed in both groups.

RESULTS

Compared with the dexamethasone group, the gamma globulin group had a significantly shorter onset time of rash, a significantly shorter time to complete regression of rash, a significantly shorter time to abdominal pain remission, and a significantly shorter time to disappearance of bloody stool, as well as comparable time to vomiting remission and length of hospital stay. The gamma globulin group had a significantly higher response rate than the dexamethasone group (95% vs 65%; P<0.05) and a significantly lower recurrence rate within 6 months than the dexamethasone group (5.6% vs 33.3%; P<0.05).

CONCLUSIONS

High-dose gamma globulin pulse therapy has a marked clinical effect in the treatment of abdominal HSP. It is safe and reliable and has a low recurrence rate, and therefore, it holds promise for clinical application.

Use of Gammaglobulin to Lower Elevated Natural Killer Cells in Patients with Recurrent Miscarriage

OBJECTIVE

To evaluate the effectiveness of intravenous immunoglobulin (IVIG) in patients presenting with recurrent miscarriage and abnormally elevated natural killer (NK) cells.

STUDY DESIGN

This retrospective patient controlled evidence level II-2 pilot study was conducted at Cohen Center, P.A., Medical City Dallas Hospital. Ninety women with a history of recurrent miscarriage (average, 5) and elevated NK cells were retrospectively evaluated to document the outcome of their treatment with IVIG.

RESULTS

Of 90 women with elevated NK cells who received IVIG treatment, 78 (86.7%) became pregnant. Sixty-four (82.0%) of those pregnancies had a successful viable outcome. Fourteen (18.0%) gestations ended as first trimester miscarriages.

CONCLUSION

We conclude at evidence level II-2 that, with adequate precautions, low-dose IVIG therapy is safe and effective for women with immunologic abortion and documented abnormally elevated NK cells.

[Adverse events in 1395 infusions with different intravenous gammaglobulin products]

The processes of isolation and sterilization of intravenous gamma globulin (IVIG) affect the end product characteristics and, therefore, its tolerability. Different products have different incidences of adverse reactions. The aim of this study was to quantify the immediate adverse events (AE) caused by the different IVIG preparations. We analyzed 1 395 infusions in 28 patients, with a median of 32.5 per subject (range 2-214), using six different IVIG preparations, with an average dose 40.3 ± 8.3 g. One thousand and thirty-one infusions were analyzed retrospectively and 364 prospectively. Patients used a mean of 2.68 ± 1.8 different IVIGs, with a median of 2 (range 1-6) per person. The number of trademarks used was related to the number of infusions received, r = 0.73. AE presented in 24 (2.3%) of 1 031 infusions retrospectively analyzed, affecting 11 of 23 patients enrolled, with a mean of 2.18 ± 1.08 AE per subject. Of 24 patients and 364 infusions prospectively analyzed, AE were observed in 14 patients and in 32 (7.2%) procedures. Twenty-four (42.9%) of 56 AE were mild, 31 (55.5%) moderate and one (1.8%) severe. The infusion rate was 9.04 ± 6 g/h for those presenting AE vs. 10.6 ± 4.6 g/h for those who did not (p = 0.31, NS). The incidence, severity and proportion of patients with AE for each brand of IVIG were very different from each other. This information should be taken into account when selecting the IVIG to be used.

Immunoglobulins for preventing hepatitis A

BACKGROUND

Hepatitis A (infectious hepatitis) is a common epidemic disease. Immunoglobulins for passive immunisation are used as prevention.

OBJECTIVES

To assess the beneficial and harmful effects of the pre- and post-exposure prophylaxis with immunoglobulins for preventing hepatitis A.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, The Chinese Biomedical Database, and Science Citation Index Expanded for trials until October 2008. In addition, we read through reference lists of the identified publications and handsearched three journals.

SELECTION CRITERIA

Randomised clinical trials on immunoglobulin prophylaxis for preventing hepatitis A, irrespective of blinding, publication status, or language.

DATA COLLECTION AND ANALYSIS

Data were extracted by two authors and verified by a third author. Results were presented as relative risks (RR) with 95% confidence intervals (CI). The primary outcome was occurrence of hepatitis A (infectious hepatitis).

MAIN RESULTS

We included 13 trials with 567,476 participants randomised to pre- or post-exposure prophylaxis. The trials had high risk of bias. The trials were heterogeneous in terms of study setting, participants, interventions, and outcome measures. Our meta-analysis with six randomised trials showed that immunoglobulins, when used for pre-exposure prophylaxis, significantly reduced the number of adult patients with hepatitis A at 6 to 12 months (1020/286503 versus 761/134529; RR 0.53; 95% CI 0.40 to 0.70; random-effects model) in comparison with no intervention or inactive control. Four trials showed a similar effect in children aged 3 to 17 at 6 to 12 months follow-up (917/210822 versus 677/78960; RR 0.45; 95% CI 0.34 to 0.59). Comparing different doses of immunoglobulins, higher dosage was generally more effective than lower dosage (1.5 ml better than 0.75 ml and 0.75 ml better than 0.1 ml) in preventing hepatitis A. No significant systemic adverse events were reported. One trial showed that immunoglobulin was more effective than placebo for post-exposure prophylaxis. It appeared that there was no significant difference between immunoglobulins and inactivated hepatitis A vaccine in seroconversion to hepatitis A vaccine antibodies at four weeks (RR 1.16; 95% CI 0.98 to 1.38), but immunoglobulins were significantly less effective than vaccine regarding antibody levels at 8, 12, or 24 weeks.

AUTHORS' CONCLUSIONS

Immunoglobulins seem to be effective for pre-exposure and post-exposure prophylaxis of hepatitis A. However, caution is warranted for the positive findings due to the limited number of trials, year of conductance, and risk of bias. Conductance of rigorous trials will be justifiable.

Long-term effects of fetal and neonatal alloimmune thrombocytopenia and its antenatal treatment on the medical and developmental outcomes of affected children

Alloimmune thrombocytopenia (AIT) is characterized by severe thrombocytopenia, usually diagnosed after birth, which may result in intracranial hemorrhage (ICH) in as many as 20% of cases. The course of AIT typically worsens in subsequent pregnancies. Administration to mother of intravenous gammaglobulin (IVIG) and/or corticosteroids to increase the fetal platelet counts of a subsequent affected fetus is widely used to avoid ICH. The objective of this study was to evaluate the long-term effects of AIT and its antenatal treatment on the medical and developmental outcomes of affected children. Seventy-one pairs of untreated (older) and antenatally treated (younger) siblings with AIT were compared. A medical questionnaire and the Behavioral Assessment System for Children (BASC) were completed over the telephone by mothers. In this sample, birth platelet counts of treated fetuses were significantly higher than those of the untreated fetuses. Treated children were born at significantly lower gestational ages and with significantly lower birthweights than untreated children. No treated child suffered a perinatal ICH compared with 12 untreated siblings. Treated siblings also had fewer vision problems (three versus 14 in the untreated group). Children treated as fetuses received higher scores on the BASC Adaptive Skills Composite than their untreated siblings. The antenatal regimen of IVIG and/or corticosteroids did not affect the results. Children with AIT treated as fetuses had better long-term developmental-behavioral outcomes than their untreated siblings, perhaps because of higher in utero platelet counts. We speculate that platelets may possibly play a role in neurodevelopmental processes in the fetus.

Coronary risk factors in Kawasaki disease treated with additional gammaglobulin

AIMS

To assess the hypothesis that an additional intravenous gammaglobulin (IVGG) infusion, if administered early, may prevent coronary artery lesions (CAL) in patients with Kawasaki disease (KD) who do not respond to initial IVGG therapy.

METHODS

Forty four KD patients (17 with CAL and 27 without CAL), treated with additional IVGG because of persistent or recrudescent fever after initial IVGG therapy, were studied. Main outcome measures were the presence of CAL by echocardiography and the number of febrile days before and after start of additional IVGG infusion (pre- and post-additional IVGG).

RESULTS

In univariate analyses, risk factors for CAL were the number of febrile days pre-additional IVGG, the number of febrile days post-additional IVGG, the number of days that initial IVGG was divided over, the white blood cell count pre- and post-additional IVGG, and the C reactive protein concentration pre-additional IVGG. In a multivariate analysis, the only independent risk factor was the number of febrile days pre-additional IVGG (> or =10 days; odds ratio 7.86; 95% CI 1.44 to 42.8; p = 0.02).

CONCLUSIONS

Among KD patients with persistent or recrudescent fever after initial IVGG therapy, administration of additional IVGG before the first 10 febrile days was associated with a decreased prevalence of CAL, when compared with the prevalence in those who were retreated later. An additional IVGG infusion, if administered early, may prevent CAL in initial IVGG non-responders.

Intravenous gammglobulin-associated acute renal failure

Intravenous gammaglobulins are used for the treatment of various auto-immune hematological disorders. Renal failure is a relatively rare, but an increasingly recognized side effect of gammaglobulin therapy. Although the renal failure is usually reversible, renal replacement therapy is required occasionally. A high index of suspicion, early recognition and appropriate intervention can prevent this complication. We herewith describe two patients with an immune hematological disorder, who developed acute renal failure after treatment with intravenous gammaglobulins. A brief review of the possible risk factors, pathophysiology and management of this complication is provided.

The effect on MRI of gammaglobulin treatment in relapsing multiple sclerosis

A number of uncontrolled studies and randomised, placebo-controlled trials have shown that treatment with intravenous gammaglobulin (IVIG) reduces the exacerbation rate in relapsing multiple sclerosis (MS). Two randomised studies from Denmark and Israel, respectively have used MRI as efficacy endpoint. In a Danish crossover trial, the number of gadolinium-enhancing lesions in serial cranial MRI was significantly reduced by approximately 60% during IVIG treatment compared to placebo. Neither the Danish study nor an Israeli study were able to show significant reductions in the total lesion load on T2-weighted cranial MRI. However, the studies were either too short or comprised too few patients for showing significant differences in T2-weighted MRI. In conclusion, IVIG is of benefit to patients with relapsing MS, but larger studies are required before the place of IVIG in the treatment of MS can be established.

Overview of pharmacological treatment of Kawasaki disease

Kawasaki disease has been researched for 32 years but its aetiology is still unknown. Conventional therapy for the disease includes corticosteroids and aspirin (acetylsalicylic acid) as anti-inflammatory and/or antithrombotic agents but they have not been proven to prevent coronary artery aneurysms. Although a high incidence of liver dysfunction in Japanese patients with Kawasaki disease receiving high dose aspirin (> or =80 mg/kg/day) suggests racial differences in salicylate sensitivity, the duration of fever in patients receiving high dose aspirin is shorter than that in patients receiving moderate dosages (30 to 50 mg/kg/day). Furthermore, most corticosteroid-resistant patients were found to develop coronary artery aneurysms, many of which were large. With the clarification of the pathogenesis and clinical features of Kawasaki disease, advances in its treatment have been achieved. The introduction of high-dose intravenous gamma-globulin (IVGG) was an epoch in this field and IVGG is now a standard therapy with the incidence of persistent coronary aneurysms 1.9% in children with the disease receiving IVGG. Today, research is mainly directed toward the treatment of IVGG-resistant patients. One to 3 days of pulsed doses of methylprednisolone (30 mg/kg/day) or readministration of IVGG 1 g/kg (once to several times) has been recommended for patients with IVGG-resistant Kawasaki disease.

[Aseptic meningitis induced by high-dose gamma-globulin in an adult woman with antiphospholipid syndrome and chronic idiopathic thrombocytopenic purpura]

It is well known that the administration of high-dose gamma-globulin concentrate is effective in alleviating thrombocytopenia in patients with idiopathic thrombocytopenic purpura (ITP). However, treatment can sometimes induce aseptic meningitis. A 25-year-old Japanese woman with antiphospholipid syndrome and ITP was conditioned with high-dose gamma-globulin concentrate prior to splenectomy. Three days after the initial gamma-globulin course, she experienced severe headache, vomiting, and high-grade fever. Cerebrospinal fluid examination yielded a diagnosis of aseptic meningitis. The patient's clinical symptoms and abnormal cerebrospinal fluid findings disappeared immediately after the discontinuation of gamma-globulin therapy. Cases of aseptic meningitis induced by high-dose gamma-globulin therapy are uncommon in the literature, and most involve children. Moreover, to our knowledge, only 1 Japanese adult ITP case of gamma-globulin-induced aseptic meningitis has been reported to date. Aseptic meningitis may be one of the important adverse effects of the administration of high-dose gamma-globulin concentrate to pediatric as well as adult ITP patients.

Congenital anomalies in two infants born after gestational gamma-globulin prophylaxis

The offspring of two women given prophylactic gamma-globulin 50 and 54 days after their last menstrual periods had congenital duodenal stenosis and a paraoesophageal hiatus hernia, respectively. The possibility that gamma-globulin may have contributed to these malformations is discussed.

[The use of gammaglobulin for preventing infection in stroke]

In the study the influence of giving gammaglobulin on the course of stroke was tested. The trial was double blind, with a control group and with a randomised administering of gammaglobulin and placebo. The condition for including a patient in the trial was clinical diagnosis of stroke, period of time from the onset not longer than five days, and the absence of both clinical and laboratory features of infection. 36 patients were given gammaglobulin (Veinoglobulin Institut Merieux) in 10 g doses at 3-day intervals, 35 patients were given placebo: 10g of albumin. The clinical follow-up lasted 30 days. Three patients from the gammaglobulin group and nine patients from the placebo group died. Administration of gammaglobulin decreased the tisc of death by 74%. The improvement of neurological deficit in 30-day survivals in the treated group was more expressed than in the placebo group. The total number of infections, number of days with increased temperature, number and time of given antibiotics were comparable in both groups. The results obtained suggest that prophylactic treatment with gammaglobulin does not prevent infections but their course is milder with consequent better clinical improvement and lower mortality.

Horse gammaglobulin-induced thrombocytopenia in anaphylaxis involving sequestration and activation of platelets

Thrombocytopenia as well as hemoconcentration and leukopenia followed by leukocytosis were induced after HoGG challenge on HoGG-sensitized mice. Thrombocytopenia was induced within 2 min and sustained for 1 day. HoGG-induced thrombocytopenia was not observed until day 10 after sensitization; mice challenged with HoGG dose > or = 10 micrograms developed thrombocytopenia. Two types of thrombocytopenia were observed in appropriately sensitized mice. HoGG induced thrombocytopenia at 2 min and 60 min, whereas, alpha-macroglobulin induced thrombocytopenia at 2 min, the platelet count of which returned to normal within 60 min. Poly (Glu60Ala30Tyr10) did not induce thrombocytopenia at 2 min or 60 min. The tracing study by 3H-serotonin labelled platelets demonstrated the 2 min-sequestration of platelets in lungs or livers. The HoGG-induced sequestration of platelets at 2 min was blocked by high dose heparin or Cobra Venom factor. Platelet activation at 60 min was partially inhibited by dexamethasone, rhodostomin synthetic peptide 45-59, or platelet activation factor antagonist (WEB 2086). Furthermore, the thrombocytopenia could be transferred by heat (56 degrees C, 4h) treated immune sera. This suggests that HoGG-induced, non-IgE-mediated thrombocytopenia in anaphylaxis involves sequestration and activation of platelets. The sequestion in lungs occurs within 2 min and can be inhibited by high dose heparin or Cobra Venom factor. The activation of platelets involves platelet activation factor, and fibrinogen receptor.

[The use of human gamma globulin in the treatment of common variable immunodeficiency]

BACKGROUND

The indication for treatment with human gammaglobulin in patients with primary hypogammaglobulinemia is well established. Nonetheless, there are no uniform criteria with regard to dose, periodicity and route of administration.

METHODS

Twenty-seven patients with common variable immunodeficiency (CVI) who received i.m. or i.v. treatment with gammaglobulin were studied, evaluating the secondary effects, stable levels of IgG achieved, control of symptomatology, clinical evolution and the need for adjuvant therapies.

RESULTS

Intravenous administration was more effective than intramuscular administration to achieve higher total IgG serum levels (5.2 +/- 1.2 vs 3.5 +/- 1.6 g/l; p = 0.07) in a shorter period of time (2.1 +/- 1.6 months vs 6.3 +/- 2.8 months; p < 0.01) and with new few secondary effects. The dose and periodicity of the treatment was individualized in each patient on the basis of the needs of consumption and the speed of metabolism of the gammaglobulin, with patients with chronic bronchial suppuration and diarrhea being those requiring the greatest doses (p < 0.0001) and a short interdosis time interval (19.2 +/- 3.1 vs 23.6 +/- 3.6 days; p = 0.01). Treatment with human gammaglobulin allowed the control of recurrent bacterial infection; however, adjuvant treatment with respiratory physical measures and antibiotics were required in patients with chronic bronchial suppuration to avoid progressive alteration of respiratory function.

CONCLUSIONS

The administration of human gammaglobulin at adequate doses and frequency is effective to control infection, avoid the development of chronic bronchial disease, alteration of pulmonary function and the appearance of other complications. Intravenous route is safer and produces fewer secondary effects than intramuscular administration with the doses and period of the treatment requiring individualization for each patient.

[Side effects of administration of gamma globulin preparations in patients with primary agammaglobulinemia]

Eight patients with adverse reactions were observed in a group of 20 primary agammaglobulinaemic patients treated with gammaglobulin derivatives. In four cases only sporadic reactions were observed, but in 2 cases repeated reactions made gammaglobulin therapy impossible. In the remaining two patients a change of gammaglobulin derivatives made adequate therapy possible. Possible causes of adverse reactions during gammaglobulin treatment and their prevention are discussed.

Home treatment of hypogammaglobulinaemia with subcutaneous gammaglobulin by rapid infusion

Intramuscular and intravenous gammaglobulin treatment for hypogammaglobulinaemia is often associated with systemic adverse reactions in some patients. Subcutaneous infusions of gammaglobulin are usually given at a slow rate. To assess the safety of home treatment with subcutaneous gammaglobulin, rapid infusions (34-40 ml/h) given by small portable pumps were used to treat twenty-five patients with hypogammaglobulinaemia. Fifteen patients had previously had adverse reactions to intramuscular or intravenous gammaglobulin treatment. After the patients had been taught how to use the pumps during 6 months of treatment in hospital, in which they initially received 100 mg of an intramuscular gammaglobulin preparation/kg per week, they went on to use the pumps at home or at work. So far, the patients have given themselves 3232 rapid subcutaneous infusions (2308 in home therapy). A median pre-infusion serum IgG concentration of 8.1 g/l resulted after 6 months of treatment. There were only 30 (0.93%) mild systemic adverse reactions; there were fewer reactions with subcutaneous gammaglobulin than with previously given intramuscular injections (n = 21, p less than 0.001) or intravenous infusions (n = 9, p less than 0.001) in this group of patients. Overall, the patients spent 0.2 days a year in hospital due to respiratory tract infections. The findings show that the method for subcutaneous administration is very easy to learn and is appreciated by the patients; moreover, the infusions can be given much faster than previously reported without any pronounced local reaction.

A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome

BACKGROUND

Treatment of acute Kawasaki syndrome with a four-day course of intravenous gamma globulin, together with aspirin, has been demonstrated to be safe and effective in preventing coronary-artery lesions and reducing systemic inflammation. We hypothesized that therapy with a single, very high dose of gamma globulin would be at least as effective as the standard regimen.

METHODS

We conducted a multicenter, randomized, controlled trial involving 549 children with acute Kawasaki syndrome. The children were assigned to receive gamma globulin either as a single infusion of 2 g per kilogram of body weight over 10 hours or as daily infusions of 400 mg per kilogram for four consecutive days. Both treatment groups received aspirin (100 mg per kilogram per day through the 14th day of illness, then 3 to 5 mg per kilogram per day).

RESULTS

The relative prevalence of coronary abnormalities, adjusted for age and sex, among patients treated with the four-day regimen, as compared with those treated with the single-infusion regimen, was 1.94 (95 percent confidence limits, 1.01 and 3.71) two weeks after enrollment and 1.84 (95 percent confidence limits, 0.89 and 3.82) seven weeks after enrollment. Children treated with the single-infusion regimen had lower mean temperatures while hospitalized (day 2, P less than 0.001; day 3, P = 0.004), as well as a shorter mean duration of fever (P = 0.028). Furthermore, in the single-infusion group the laboratory indexes of acute inflammation moved more rapidly toward normal, including the adjusted serum albumin level (P = 0.004), alpha 1-antitrypsin level (P = 0.007), and C-reactive protein level (P = 0.017). Lower IgG levels on day 4 were associated with a higher prevalence of coronary lesions (P = 0.005) and with a greater degree of systemic inflammation. The two groups had a similar incidence of adverse effects (including new or worsening congestive heart failure in nine children), which occurred in 2.7 percent of the children overall. All the adverse effects were transient.

CONCLUSIONS

In children with acute Kawasaki disease, a single large dose of intravenous gamma globulin is more effective than the conventional regimen of four smaller daily doses and is equally safe.

[Effectiveness of intravenous immunoglobulins in polymyositis and dermatomyositis. An open trial in 15 patients]

Polymyositis (PM) and dermatomyositis (DM) are dysimmune diseases usually treated with corticosteroids and immunosuppressants. Human polyvalent immunoglobulins administered intravenously (IgIV) are known to be effective in some dysimmune diseases. Between August 1987 and September 1989 we conducted an open trial of IgIV in 15 patients (mean age 44 +/- 14 years) with either PM (12 cases) or DM (3 cases) associated with a collagen disease in 2 patients. In 14 of these 15 patients the conventional treatments (corticosteroids, immunosuppressants, plasmapheresis, total body irradiation, lymphopheresis) had failed. One patient was seropositive for picornavirus and received IgIV as initial treatment. IgIV infusions were given 4 +/- 3.9 years on average after the onset of PM or DM. Twelve of the 15 patients received another treatment, starting at least 6 weeks before IgIV and pursued without dosage increase, which consisted of corticosteroids (11 cases), methotrexate (5 cases) or plasmapheresis (1 case). Human polyvalent immunoglobulins for intravenous use were prescribed in doses of 2 g/kg/monthly course. All but two patients (1 course) received 3 to 6 courses on average. The IgIV infusions were well tolerated in 12 patients; 3 patients showed allergic manifestations which regressed. Therapeutic effectiveness was evaluated by muscle testing and by repeated assays of creatine phosphokinase (CPK). Clinical improvement, usually perceptible after the first course, was observed in 13/15 patients; it was associated with a more than 30 percent decrease of the initial CPK level in 13 patients and with a reduction of associated therapies in 9 patients. In the entire patient population a statistically significant lowering of mean CPK value was observed as early as in the first course (P less than 0.001). In view of their effectiveness, rapid action and safety, intravenous Ig infusions may be regarded as an interesting treatment in PM or DM patients.

Prospective study on the hepatitis safety of intravenous immunoglobulin, pH 4.25

Recent reports of transmission by intravenous gamma-globulin preparations of non-A non-B hepatitis (NANBH), including several cases that progressed to severe liver damage and death, have raised concerns about the safety of intravenous gamma-globulin. However, the problem does not seem to be widespread. To assess this issue, we previously reported the results of liver function tests monitored in 41 patients with primary immunodeficiency treated with intravenous immunoglobulin (IGIV), pH 4.25 over periods ranging from 6 to 15 months. Eighteen of these patients at two of the three centers have now had serial serum glutamic pyruvic transaminase (SGPT) levels performed regularly at intervals of 1-5 weeks while continuing monthly intravenous infusions of nonmodified IGIV, pH 4.25 for an additional 14-26 months. The standard dosage was 400 mg per kg body weight IGIV, pH 4.25. Six lots of IGIV, pH 4.25 were used. Transient minor SGPT elevations were observed in 5 of the patients on a total of 8 occasions. None of the elevations was considered indicative of NANBH or of any chronic hepatic disease. All patients remained negative for hepatitis B surface antigen throughout the study.

A seral epidemiological study of HIV transmitted through human seral gamma-globulin preparations

In order to study the potential risk of transferring HIV through human seral gamma-globulin preparations (immunoglobulin), indirect immunofluorescent antibody test (IFA) and Western Blot (WB) assay were applied to 343 random samples (sera) with previous injection of imported human seral gamma-globulins (Ig) positive for Human Immunodeficiency Virus (HIV) antibodies between 1981-1987 for the detection of HIV antibodies. All results were negative and tests on all 23 controls who had previously received Ig made in China also gave negative results. However all 12 batches of imported Ig collected from the above-mentioned users, were positive for HIV antibodies when tested by WB and IFA. This study shows that under normal conditions, human seral gamma-globulin does not transmit HIV.

Intravenous gamma-globulin: clinical applications in pediatric care

Intravenous gamma-globulin is being used with increasing frequency in the care of children. This article reviews the physiology of the immune system, the pharmacology of intravenous gamma-globulin, and presents four case studies. Administration guidelines, adverse reactions, and appropriate interventions are discussed. A table comparing four commonly used products is presented.

[High-dose gamma globulin in autoimmune diseases]

The short-term benefit of high-dose intravenous gammaglobulin (IvIgG) in autoimmune diseases is widely accepted in patients with chronic immune thrombocytopenic purpura (ITP). Recent studies reported remission or stabilization of the disease in some patients receiving long-term IvIgG therapy. It has been suggested that this long-term effect may be due to antiidiotypic antibodies in IvIgG down-regulating the immune response in chronic ITP. Because of the high costs and the transient effect in most instances, this treatment should not be used routinely. IvIgG may be considered in severely thrombocytopenic patients with chronic ITP who develop serious bleeding.

Differences in immunoglobulin preparations for intravenous use: a comparison of six products

The use of intravenous gamma globulin products in both children and adults has increased markedly over the past 5 years, since these agents were licensed in the United States. Product competition has become fierce, with each supplier touting the merits of its own product. A summary of the six products currently available in the United States is presented. Comparisons are made according to method of product manufacture, product specifications, antibody titers, opsonization data, IgG subclass quantification, ease of administration, and side effects.

Pharmacokinetics of intravenous immunoglobulin in very low birth weight neonates

We studied the pharmacokinetics of single doses of intravenous immunoglobulin (IVIG) of 1000, 750 and 500 mg/kg administered to 21 neonates with birth weights from 750 to 1500 g. No adverse effects were detected. Mean pharmacokinetic values for the large, intermediate and small dose groups, respectively, were: elimination half-life, 19.6, 28.7 and 22.1 days; clearance, 5.2, 5.6 and 3.7 ml/kg/day; volume of distribution, 151, 255 and 130 ml/kg. Mean peak IgG concentrations in serum were 1826, 1476 and 1257 mg/dl for the large, intermediate and small dose groups, respectively. Mean IgG on post-infusion Days 1 to 28 were similar for the intermediate and small dose groups but were higher in the larger dose group. Both large and intermediate doses achieved larger increases in IgG over preinfusion values (delta IgG) than the small dose. The differences in delta IgG between the large and intermediate doses were less notable. The wide variability observed indicates that individualization of intravenous immunoglobulin dosage will be required in these patients.

Polyclonal rabbit gamma globulins against a human cytotoxic CD4 T cell clone. II. Use in prevention of rejection in kidney transplantation: a pilot study

Antiblast globulins (GAB) were prepared by immunization of rabbits with activated T lymphocytes (AT) derived from a rejected kidney allograft. AT consisted of a CD4+ (CD3+, CD2+ TCR alpha+ beta+) clone cytotoxic for HLA DR8-positive targets. The immunizing cells were adapted to industrial growth conditions by repetitive stimulations with an EBV-transformed line from the kidney donor and recombinant IL-2. In the pilot study, GAB (1.0-1.5 mg/kg/day) was given in 12-hr infusions, in association with prednisone (Pred) 1 mg/kg/day and azathioprine (Aza) 2 mg/kg/day, as prophylactic treatment of rejection in 12 kidney-transplanted patients during the first 2 weeks postgrafting. GAB dosage was further adapted according to the level of circulating E-rosette-forming T cells (ERFT). Cyclosporine A (8 mg/kg/day) was given at day 14 as a monotherapy after Pred and Aza were progressively tapered. No patient died, but one kidney was lost from surgical complication. No rejection occurred under GAB treatment; 41% of patients had at least one episode in the first 3 months and 16% from 3 to 9 months. GAB side effects were minor (skin rash: 2, low grade fever: 4) except for one acute serum sickness. Platelet and white blood cell counts were unchanged, but there was a significant decrease in hemoglobin during the 2 weeks of GAB infusions. Few infectious episodes occurred (3 bacterial, 2 viral). GAB monitoring showed a dramatic drop in T11+, T3+, T4+, and T8+ circulating T cells (less than 10% of normal values between days 3 and 14), whereas EFRT cells had a delayed and somewhat lower decrease (less than 10% after day 6 only). Consequently, mean GAB doses had to be raised to 1.3 mg/kg/day at day 4 and 1.6 at days 8 and 14. This pilot study suggests that this new bioreagent should be of major interest in the prophylaxis and treatment of rejection in allograft recipients. A controlled study is in progress.

Follow-up of anti-IgA antibodies in primary immunodeficient patients treated with gamma-globulin

The levels of anti-IgA antibodies and the appearance of adverse reactions following gamma-globulin administration in 41 patients affected by primary antibody defects treated with intramuscular (IMGG) or intravenous gamma-globulin (IVGG), and 3 patients with the Wiskott-Aldrich syndrome (WAS) have been studied during a 31-month period. Anti-IgA antibodies were restricted to patients with circulating B lymphocytes and measurable amounts of IgA. The incidence of anti-IgA antibodies in the immunodeficient patients studied was 22.7%, and 2 of the 3 WAS patients also had high levels of anti-IgA antibodies. The presence of moderate levels of anti-IgA antibodies (up to 1/1,600) was not associated with adverse reactions. Our results indicate a significant relationship (p less than 0.02) between persistence of anti-IgA antibodies and IMGG administration.

High dose intravenous gammaglobulins in autoimmune disorders: mode of action and therapeutic uses

Gammaglobulins administered intramuscularly have been used for more than 40 years to treat antibody deficiency states. In the last decade intravenous preparations were developed. They do not aggregate and contain IgG molecules with intact recognition and effector functions. These compounds are safe and only minor side effects were reported even when high doses were given. While studying their effect when given in high doses to hypogammaglobulinemic patients, an accidental finding was observed regarding their beneficial effect in idiopathic thrombocytopenic purpura (ITP). This observation led to many studies looking at the effect of high dose gammaglobulin in several other autoimmune diseases. While the effect in acute ITP is well established, there are encouraging reports in respect to the effect of intravenous gammaglobulin in many other disorders, but no final conclusion can be drawn due to the small numbers of cases studied. The mechanism by which intravenous gammaglobulin exerts its function is still unclear. It may work through the Fc receptor in the reticuloendothelial system, as an immunoregulator agent or interact in the idiotype-antiidiotype network. Intravenous gammaglobulin seems to be an important therapeutic tool in a large number of autoimmune disorders of various etiologies.

Anti-IgA antibodies in selective IgA deficiency and in primary immunodeficient patients treated with gamma-globulin

Sera from 106 blood donors, 40 patients with primary immunodeficiencies (ID) treated with gamma-globulin, and 46 patients with selective IgA deficiency were analyzed by an enzyme-linked immunosorbent assay for anti-IgA antibodies. Increased levels of antibodies to IgA were found in 5.6% of the blood donors, 17.5% of the ID patients, and 36.8% of the isolated IgA deficiencies. The percentage was higher in patients with IgA and IgG2 deficiencies (50%). The percentage of patients having increased levels of anti-IgA antibodies was similar to the total prevalence of the 10 other autoantibodies studied. These anti-IgA antibodies were mainly of the IgG class, except from one blood donor with IgM antibodies, and two patients, one with isolated IgA deficiency and the other with common variable immunodeficiency who had anti-IgA antibodies of the IgE class. The latter patient developed a near fatal anaphylactic reaction when intravenous gamma-globulin was administered. Most of the patients with severe adverse reactions to gamma-globulin did not present anti-IgA antibodies. Our data suggest that at least in some immunodeficient patients the elevated amounts of anti-IgA antibodies are not related to the administration of exogenous IgA. The importance of measuring anti-IgA antibodies of the IgG and IgE isotypes in IgA-deficient patients as well as in patients in treatment with gamma-globulin is emphasized.

Alpha interferon treatment of chronic non-A, non-B hepatitis caused by intravenous gammaglobulin

Two patients with hypogammaglobulinemia and chronic active non-A, non-B hepatitis caused by intravenous gammaglobulin substitution were treated long-term with alpha-2b interferon (Introna). Both achieved normal aminotransferase levels within 2-12 weeks after initiation of interferon therapy. One patient was rebiopsied after 6 months of therapy and showed some degree of improvement in the liver inflammatory activity. The beneficial effects warrant a randomized controlled study.

Intravenous immunoglobulin therapy of idiopathic thrombocytopenic purpura in childhood and adolescence

Intravenous immunoglobulin is not only a dramatic clinical therapy, but it is also extremely interesting in regard to mechanism of action. The high cost of therapy limits its application, yet it appears to be equal to or perhaps slightly more effective than corticosteroids as a treatment of ITP and is far less toxic with prolonged use. The appropriate place for its exact use remains to be determined but probably includes patients urgently requiring rapid platelet increases (in conjunction with steroids), treatment of immunocompromised patients, and treatment of chronic patients, either children to avoid splenectomy or adults with severe disease after splenectomy. Controlled trials to resolve these clinical questions are urgently needed. Existing studies on its mechanisms of actions are very interesting and have furthered our understanding of the pathophysiology of ITP. Although future work may lead to further applications, initial enthusiasm for the use of IVGG in the treatment of other autoimmune diseases with the exception of myasthenia gravis has been limited by subsequent clinical experience.

Alpha-interferon therapy for non-A, non-B hepatitis transmitted by gammaglobulin replacement therapy

Three hypogammaglobulinaemic patients with non-A, non-B hepatitis transmitted by gammaglobulin replacement therapy were treated with lymphoblastoid alpha-interferon. All showed a striking improvement in serum aminotransferases after the start of each course of treatment.

LAV/HTLV-III antibodies in patients treated with intravenous gammaglobulins

The test sera from 50 patients treated with intravenous gammaglobulins (IVG) were examined for LAV/HTLV-III antibody by ELISA tests in order to evaluate the risk of transmission of LAV/HTLV-III virus via administration of IVG. The three ELISA-positive sera were negative for the antibody by both indirect immunofluorescence assay (IFA) and Western blot assay (WBA). Thus, all of the test sera were negative for LAV/HTLV-III antibody. Two of the ELISA-positive/IFA-negative/WBA-negative samples had HLA-DR4 antibodies causing positive ELISA results.

C1 esterase inhibitor deficiency in X-linked hypogammaglobulinaemia: an anomaly fostering anaphylactoid reactions following intramuscular gammaglobulin administration

A patient with apparent X-linked agammaglobulinaemia was found to be inordinately susceptible to anaphylactoid reactions to intramuscular injections of gammaglobulin. The patient was found also to have low levels of C1 esterase inhibitor (C1 INH). The possibility that the C1 INH deficiency and in this patient, whether genetic or acquired, fostered the susceptibility to the production of anaphylactoid reactions after gammaglobulin injections urges further studies of the association of C1 INH deficiency and anaphylactoid reactions to gammaglobulin injections. The possibility that C1 INH levels like C1q levels may be low in hypogammaglobulinaemic patients as a consequence of increased catabolism of this regulator of the complement system when IgG levels are low is considered.