The Potential Impact of Substitutive Therapy With Intravenous Immunoglobulin on the Outcome of Heart Transplant Recipients With Infections

Abstract

Hypogammaglobulinemia has been proposed to be a risk factor for infection after heart transplantation (OHT). Infection is a leading cause of morbility and mortality among these patients. In a retrospective study we analyzed the impact of substitutive therapy with nonspecific intravenous immunoglobulin (IVIG) on the outcomes of heart transplant patients with infections. We analyzed the outcome of 123 consecutive heart transplant recipients in our center from June 1996 to November 2005. Their mean age was 53 years (range = 22 to 69 years), and the mean follow-up = 51 months, (range = 1 to 124 months). Twenty-nine patients with hypogammaglobulinemia (mean serum immunoglobulin G levels = 480 mg/dL) experienced severe infections due to cytomegalovirus (CMV) disease, n = 4; CMV disease + another infection, n = 6; CMV infection, n = 4; CMV infection + other infection, n = 3; pulmonary nocardiosis, n = 2; recurrent pneumonia, n = 2; clostridium-difficile-associated diarrhea, n = 2; pulmonary tuberculosis, n = 1; bacterial infections, n = 5. They were treated with IVIG (400 mg/kg every 21 days) with the goal to reach normal serum immunoglobulin G levels (>700 mg/dL). Overall ( n = 123), a logistic regression analysis showed IVIG therapy to be associated with a decreased risk of death [odds ratio (OR) = 0.204, 95% confidence interval (CI) = 0.04 to 0.92, P = .03]. Among patients who developed infections during follow-up ( n = 70), IVIG therapy was also associated with a lower risk of death (OR = 0.104, CI = 0.02 to 0.50, P = .0047). When we stratified patients with CMV disease ( n = 24) according to the presence ( n = 10) or absence ( n = 14) of IVIG therapy, the mortality rate of IVIG-treated patients was 20% versus 71% for non-IVIG treated patients [OR = 0.06, CI = 0.0060 to 0.63, P = .01]. The use of nonspecific IVIG in OHT with hypogammaglobulinemia and infections might reduce the risk of death. Randomized studies in a larger cohort of patients are necessary to confirm these results.