There has been an association between post solid organ transplant (SOT) hypogammaglobulinemia and infections, but the benefit of immunoglobulin (Ig) replacement has been less clear. We hypothesize that (1) only a subset of patients with post-SOT hypogammaglobulinemia have impaired antibody responses; (2) empiric Ig replacement before checking antibody responses may commit some patients to unnecessary therapy; and (3) patients with impaired antibody responses have fewer infections after replacement. METHODS: Epic Slicer Dicer was used to retrospectively identify patients with lung or kidney transplants evaluated by the Immunodeficiency Clinic at Johns Hopkins (2010-2019) for hypogammaglobulinemia (n5 59). Pneumococcal conjugate vaccine challenge titers to assess antibody responses were obtained. If titers revealed protection to fewer than 6/14 serotypes (cutoff 1.0 ug/ml) then patients were started on replacement. Data on severity, type, frequency of infections was collected. RESULTS: 27/36 SOT patients with hypogammaglobulinemia (median Ig level: 445 mg/dl, range: 199-634 mg/dl) had impaired antibody responses, and started replacement. They had a mean of 2.18 infections/year and median of 1 infection/year before replacement. After replacement they had a mean of 1.08 infections/year and median of 1 infection/year. 9/36 SOT patients with hypogammaglobulinemia (median Ig level: 458 mg/dl, range 354-511 mg/dl) had normal antibody responses and did not start replacement. They had a mean of 1.22 infections/year and median of 1 infection/year. CONCLUSIONS: Only a subset of patients with post-SOT hypogammaglobulinemia have evidence of impaired humoral response necessitating Ig replacement. This parameter can help identify patients who may benefit most from Ig replacement to reduce infectious complications.
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