Hypogammaglobulinemia after cardiopulmonary bypass in infants

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 147; no. 5; pp. 1587 - 1593.e1
• Main Authors: Rhodes, Leslie A., MD, Robert, Stephen M., MD, Atkinson, T. Prescott, MD, Dabal, Robert J., MD, Mahdi, Alla M., MPH, Alten, Jeffrey A., MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.05.2014
• Subjects: Acute Kidney Injury - epidemiology; Agammaglobulinemia - blood; Agammaglobulinemia - diagnosis; Agammaglobulinemia - epidemiology; Agammaglobulinemia - immunology; Alabama - epidemiology; Biomarkers - blood; Capillary Permeability; Cardiopulmonary Bypass - adverse effects; Cardiothoracic Surgery; Cross Infection - epidemiology; Cytokines - blood; Female; Heart Defects, Congenital - surgery; Humans; Immunoglobulins - blood; Incidence; Infant, Newborn; Inflammation Mediators - blood; Intensive Care Units, Neonatal; Length of Stay; Male; Respiration, Artificial; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Water-Electrolyte Balance; Alabama; VAP; CICU; bloodstream infection; FFP; fresh frozen plasma; systemic inflammatory response syndrome; 41.1; cardiopulmonary bypass; 41.2; BSI; intravenous immunoglobulin; AKI; operating room; packed red blood cell; OR; immunoglobulin; POD; postoperative day; PRBC; IVIG; ventilator-associated pneumonia; cardiac intensive care unit; SIRS; CPB; PD; acute kidney injury; peritoneal dialysis; 41; 20; Ig
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2013.07.040

Background Hypogammaglobulinemia has been reported after cardiac surgery and may be associated with adverse outcomes. We sought to define baseline immunoglobulin (Ig) concentration in neonates and infants with congenital heart disease, determine their course after cardiopulmonary bypass (CPB), and determine if post-CPB hypogammaglobulinemia was associated with increased morbidity. Methods This was a single-center, retrospective analysis of infants who underwent cardiac surgery with CPB between June 2010 and December 2011. The Ig concentration was obtained from banked plasma of 47 patients from a prior study (pre-CPB, immediately post-CPB, and 24 and 48 hours post-CPB). In addition, any Ig levels drawn for clinical purposes after CPB were included. Ig levels were excluded if drawn after chylothorax diagnosis or intravenous IgG administration. Results The median age was 7 days. Preoperative Ig concentration was similar to that described in healthy children. IgG level decreased to less than 50% of preoperative concentration by 24-hour post-CPB and failed to recover by 7 days. Of 47 patients, 25 (53%) had low IgG (<248 mg/dL) after CPB. Despite no difference in demographics or risk factors between patients with low and normal IgG, low IgG patients had more positive fluid balance at 24 hours and increased proinflammatory plasma cytokine levels, duration of mechanical ventilation, and cardiac intensive care unit length of stay. In addition, low IgG patients had an increased incidence of postoperative infections (40% vs 14%; P  = .056). Conclusions Hypogammaglobulinemia occurs in half of infants after CPB. Its association with fluid overload and increased inflammatory cytokines suggests it may result from capillary leak. Postoperative hypogammaglobulinemia is associated with increased morbidity, including more secondary infections.