Immunoglobulin Supplementation Practices and Effects During Pediatric B-Cell Acute Lymphoblastic Leukemia Therapy

Although some children with B-cell acute lymphoblastic leukemia (B-ALL) receive intravenous immunoglobulin (IVIG) during conventional therapy, supplementation practices vary, and data describing the indications and their impact are lacking. In this single-institution cohort of children with B-ALL receiving conventional chemotherapy, we evaluate associations of patient and disease characteristics with IVIG supplementation, describe infection-related outcomes by IVIG receipt, and describe outcomes after IVIG supplementation. Multivariable logistic regression models identified factors associated with IVIG receipt. Of 373 eligible patients with B-ALL who did not receive immune therapy, 251 (67.3%) had an IgG level checked, and 114 (30.6%) received IVIG. The median IgG nadir was lower in IVIG recipients versus nonrecipients (404 vs. 675 mg/dL, P<0.01). IVIG recipients were younger at diagnosis (4 vs. 6 y, P<0.01) and had a larger number of severe infections per 1000 leukemia treatment days (4.2 vs. 2.5, P<0.01). In adjusted models, the odds of IVIG administration were lower for non-white patients (OR=0.43, 95% CI=0.22-0.83), higher for patients with >2 severe infections during treatment (OR=2.57, 95% CI=1.28-5.18), and higher for National Cancer Institute standard risk patients with IgG nadir <500 mg/dL (OR=7.45, 95% CI=3.54-15.70). For IVIG recipients, the rate of emergency department visits, severe infections, and febrile neutropenia episodes was 5.4, 1.9, and 1.1 per 1000 treatment days, respectively, during IVIG supplementation. Among children with B-ALL receiving conventional chemotherapy, clinical characteristics differ between IVIG recipients and nonrecipients. Uniform IgG measurements during therapy may guide supplementation decisions, especially in the era of frontline immunotherapy.