12/5/2012
I have recently seen two challenging cases of patients with CVID (both dx'd by decreased IgG and decreased but not absent IgA with impaired Ab response to vaccines) and would welcome your input on my questions.

The first patient is a 75yo woman with recurrent pneumonia and CVID. She started IVIg and improved significantly clinically with a marked decrease in infections. 6 months after starting IVIg, however, she had what was thought to be a TIA, with no resultant disability. After discussion with the pt and neurologist, I d/c'd her IVIg, and she has not had any further neurologic events- but has had 3 pulmonary infections since then. I would like to at least consider reinitiating Ig replacement. Is there any evidence that certain IVIg or SqIg preps would be preferred?

My second patient is a 68yo woman newly dx'd with CVID with recurrent pneumonia and ESRD on hemodialysis, currently undergoing work-up for possible transplant with a kidney to be donated by her daughter. She also has a history of one CVA a year ago and CAD, s/p CABG. According to the transplant team, CVID is not an absolute contraindication to renal transplant. Again, is there any preferred IVIg or SqIg prep in this situation? How should dosing be adjusted for either IV or SQ administration in dialysis patients?

Thank you for your inquiry.

I am referring your question to Dr. Arnold Levinson, who has a great deal of experience dealing with common variable immunodeficiency patients and replacement immunoglobulin therapy in this disorder. When I hear from Dr. Levinson, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Arnold Levinson. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Arnold Levinson:
Patient 1 - Recommend starting subq Ig in standard dosing. I'm not aware of any increased risk of thrombotic events with this formulation.

Patient 2 - Again, subq likely safest approach. No need for adjustment of dose with hemodialysis given the size of IgG molecule. However, if extracellular fluid volume increases, the IgG on board would be distributed into a bigger space and therefore diluted. So, would advise periodic measurements.

Arnold Levinson, M.D.