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Highly Accessed Review

Bench-to-bedside review: Immunoglobulin therapy for sepsis - biological plausibility from a critical care perspective

Manu Shankar-Hari123*, Jo Spencer2, William A Sewell4, Kathryn M Rowan3 and Mervyn Singer5

Author Affiliations

1 Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK

2 School Of Medicine, Kings College London, Strand, London WC2R 2LS, UK

3 Intensive Care National Audit and Research Centre (ICNARC), Tavistock House, Tavistock Square, London WC1H 9HR, UK

4 Scunthorpe General Hospital, Scunthorpe, North Lincolnshire DN15 7BH, UK

5 Bloomsbury Institute of Intensive Care Medicine, University College London, London WC1E 6BT, UK

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Critical Care 2011, 16:206  doi:10.1186/cc10597

Published: 16 March 2012

Abstract

Sepsis represents a dysregulated host response to infection, the extent of which determines the severity of organ dysfunction and subsequent outcome. All trialled immunomodulatory strategies to date have resulted in either outright failure or inconsistent degrees of success. Intravenous immunoglobulin (IVIg) therapy falls into the latter category with opinion still divided as to its utility. This article provides a narrative review of the biological rationale for using IVIg in sepsis. A literature search was conducted using the PubMed database (1966 to February 2011). The strategy included the following text terms and combinations of these: IVIg, intravenous immune globulin, intravenous immunoglobulin, immunoglobulin, immunoglobulin therapy, pentaglobin, sepsis, inflammation, immune modulation, apoptosis. Preclinical and extrapolated clinical data of IVIg therapy in sepsis suggests improved bacterial clearance, inhibitory effects upon upstream mediators of the host response (for example, the nuclear factor kappa B (NF-κB) transcription factor), scavenging of downstream inflammatory mediators (for example, cytokines), direct anti-inflammatory effects mediated via Fcγ receptors, and a potential ability to attenuate lymphocyte apoptosis and thus sepsis-related immunosuppression. Characterizing the trajectory of change in immunoglobulin levels during sepsis, understanding mechanisms contributing to these changes, and undertaking IVIg dose-finding studies should be performed prior to further large-scale interventional trials to enhance the likelihood of a successful outcome.