title: Hypogammaglobulinemia following cardiac transplantation: a link between rejection and infection.
abstract: BACKGROUND
  Hypogammaglobulinemia (HGG) has been reported after solid organ transplantation and is noted to confer an increased risk of opportunistic infections.
  
  
  OBJECTIVE
  In this study, we sought to assess the relationship between severe HGG to infection and acute cellular rejection following heart transplantation.
  
  
  METHODS
  Between February 1997 and January 1999, we retrospectively analyzed the clinical outcome of 111 consecutive heart transplant recipients who had immunoglobulin G (IgG) level monitoring at 3 and 6 months post-transplant and when clinically indicated.
  
  
  RESULTS
  Eighty-one percent of patients were males, mean age 54 +/- 13 years, and the mean follow-up period was 13.8 +/- 5.7 months. Patients had normal IgG levels prior to transplant (mean 1137 +/- 353 mg/dl). Ten percent (11 of 111) of patients developed severe HGG (IgG < 350 mg/dl) post-transplant. The average time to the lowest IgG level was 196 +/- 125 days. Patients with severe HGG were at increased risk of opportunistic infections compared to patients with IgG > 350 mg/dl (55% [6 of 11] vs. 5% [5 of 100], odds ratio = 22.8, p < 0.001). Compared to patients with no rejection, patients who experienced three or more episodes of rejection had lower mean IgG (580 +/- 309 vs. 751 +/- 325, p = 0.05), and increased incidence of severe HGG (33% [7 of 21] vs. 2.8% [1 of 35], p = 0.001). The incidence of rejection episodes per patient at 1 year was higher in patients with severe HGG compared to patients with IgG >350 (2.82 +/- 1.66 vs. 1.36 +/- 1.45 episodes/patient, p = 0.02). The use of parenteral steroid pulse therapy was associated with an increased risk of severe HGG (odds ratio = 15.28, p < 0.001).
  
  
  CONCLUSIONS
  Severe HGG after cardiac transplantation may develop as a consequence of intensification of immunosuppressive therapy for rejection and hence, confers an increased risk of opportunistic infections. IgG level may be a useful marker for identifying patients at high risk.
authors: Department of Cardiology, Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio, USA
authors: M H
authors: MH
authors: Yamani
authors: R K
authors: RK
authors: Avery
authors: S D
authors: SD
authors: Mawhorter
authors: J B
authors: JB
authors: Young
authors: N B
authors: NB
authors: Ratliff
authors: R E
authors: RE
authors: Hobbs
authors: P M
authors: PM
authors: McCarthy
authors: N G
authors: NG
authors: Smedira
authors: M
authors: M
authors: Goormastic
authors: D
authors: D
authors: Pelegrin
authors: R C
authors: RC
authors: Starling
mesh_terms: D000361:Agammaglobulinemia / Q000097:blood / Q000150:complications* / Q000209:etiology; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D005260:Female; D006084:Graft Rejection / Q000097:blood / Q000150:complications*; D016027:Heart Transplantation; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood*; D007166:Immunosuppressive Agents / Q000009:adverse effects; D007263:Infusions, Parenteral; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009894:Opportunistic Infections / Q000097:blood / Q000209:etiology*; D020551:Pulse Therapy, Drug; D012189:Retrospective Studies; D013256:Steroids / Q000009:adverse effects*
chemical_list: D015415:Biomarkers; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D013256:Steroids