Hypogammaglobulinemia Identification and Management in Lung Transplant Patients: Survey of Provider Practices

Abstract

Purpose Severe hypogammaglobulinemia (HG) in lung transplant recipients is associated with increased infections and one-year mortality. As standard protocols for HG screening and management do not exist, we surveyed lung transplant centers to characterize current practices in HG screening and management. Methods We created a survey which was reviewed by three experts in Lung Transplant Pulmonology and Allergy/Immunology. The survey consisted of eight long-answer questions, four yes/no questions, and three checkbox questions focused on IgG measurement and HG treatment practices pre- and post-lung transplant. We sent the survey to 50 physicians at 40 transplant centers internationally using Google Forms on February 4th, 2020. Results There were 24 (48%, 24/50) respondents from 19 lung transplant centers. Responses were tabulated for individual respondents as answers varied within centers. Respondents reported routinely measuring IgG levels in 54% (13/24) of pre-transplant patients and 38% (9/24) of post-transplant patients, with time points for checking IgG levels varying widely. In post-transplant patients with frequent infections, respondents reported routinely measuring IgG levels (83%, 20/24), routinely not measuring (13%, 3/24), or not having a protocol (4%, 1/24). Reported criteria for initiating IgG replacement therapy (IgG-RT) were infection frequency only (n=2), IgG level only (n=6), or some combination of the two (n=9). IgG level cutoffs utilized to initiate IgG-RT ranged from Conclusion HG screening and management practices in lung transplant recipients vary greatly, potentially leaving patients vulnerable to worse clinical outcomes. Reported barriers include lack of guidance regarding HG treatment criteria and difficulties obtaining IgG-RT. Involving immunologists in screening and treatment decision-making could mitigate some of these barriers.