Immunoglobulins in Umbilical Cord Plasma

Transcription

1 Arch. Dis. Childh., 1968, 43, 161. Immunoglobulins in Umbilicl Cord Plsm III: Hemolytic Disese of Newborn nd Respirtory Distress Syndrome RIC McKAY, HAZL THOM, nd DRK GRAY From the Deprtment of Child Helth, University of Aberdeen In study of the serum proteins in respirtory distress syndrome of the newborn (RDS), Hrdie, Heese, nd Kench (1965) found tht the concentrtion of electrophoreticlly seprted y-globulin ws significntly reduced below the levels normlly found in umbilicl cord blood, nd fell even further in the first few dys of life. Lter, Hrdie nd Kench (1967) demonstrted reduced concentrtions of y-globulin lso in the serum of mothers whose infnts developed RDS. Low levels of y-globulin were demonstrble in the mother's plsm throughout pregnncy from bout the 16th-2th week of gesttion, nd rose to norml bout 6 weeks fter delivery. One suggestion of the uthors ws tht RDS might hve n immunologicl bsis, nd they showed similr low concentrtions of y-globulin in the umbilicl cord ser of 3 infnts with hemolytic disese of the newborn. Stemnberg, Dgenis-Perusse, nd Dreyfuss (1956) hd previously shown tht the rtio of fetl to mternl y-globulin concentrtion ws lower in infnts with hemolytic disese thn in norml infnts. Similrly, Nejedld (1967) found tht the titres of vrious ntibodies cquired trnsplcentlly s well s the y-globulin concentrtion were low in infnts with hemolytic disese before exchnge trnsfusion, nd tht those infnts who hd exchnge trnsfusions showed flling concentrtions of y- globulin nd impired 7S-ntibody production for some months fter birth. These previous investigtions suggest tht the totl plsm y-globulin concentrtion my be bnormlly low in hemolytic disese of the newborn nd in RDS, nd tht in the former the immune response my be impired for some months if replcement trnsfusion is crried out. An investigtion is reported here in which the concentrtions of the individul plsm immuno- Received August 1, globulins were mesured by specific immunologicl technique in infnts hving either one of the diseses. Mteril nd Methods Selection of cses. Mternl nd umbilicl cord blood specimens were collected from rndom group of 16 cses of hemolytic disese of the newborn, nd umbilicl venous blood only from further 26 cses. In 39 of the 42 cses the incomptibility ws due to the Rhesus D ntigen, in one to Rhesus, nd in two to ABO fctors. A high titre of ntibody (1/4 or over) ws recorded during the pregnncy in 28 of the 4 rhesus cses. In 36 instnces the infnt ws treted by replcement trnsfusion shortly fter birth. The 15 cses of RDS studied were removed from series of infnts who were pprently helthy when bom nd from whom umbilicl venous blood ws collected for study of norml vlues (Thom, McKy, nd Gry, 1967b). RDS ws defined for the purposes of this study in the clinicl terms described by Troelstr et l. (1964) nd on the bsis of chrcteristic x-ry ppernces. All the infnts hd symptoms of moderte or severe degree. Mternl blood ws collected t time of delivery in 1 instnces. Three of the infnts were over 25 g. birthweight, nd the reminder under this weight, but in the 12 infnts, including 2 of the 3 over 25 g., whose gesttionl ge ws known ccurtely, it ws 37 weeks or less. The sttisticl nlysis for both hemolytic disese nd RDS ws crried out on birthweight rther thn gesttionl ge clssifiction of the infnts into premture nd mture groups, since this llowed inclusion of more cses. The results re compred with those previously found in helthy infnts (Thom et l., 1967b). Quntittion of proteins. Individul plsm proteins were quntitted by single rdil diffusion in gr s described previously (Thom, McKy, nd Gry, 1967). In the cse of IgA, preliminry screening by double diffusion in gr ws crried out. Absorption of nti-rh ntibodies. Plsm specimens t delivery from 3 women immunized ginst the 161

2 162 - u I- 3* , '. o'2- (). *. o o 4c C 2X 3 ~~~~ McKy, Thom, nd Gry lb, 9~ / D ntigen, nd the umbilicl cord plsm specimens of their children who were ll CDe/cde, were tested before nd fter bsorption with equl volumes of pooled RI R, nd R2r cells. Two of the mternl plsms contined high titre incomplete nti-rh, nd the cord plsms of their children contined this ntibody in somewht lower titre. The totl IgG concentrtions in these mothers (183 nd 1578 mg./1 ml.) were lso higher thn the concentrtions in the cord specimens (1294 nd 984 mg./1 ml., respectively), s would be expected since both were of low birthweight (2268 g. nd 2424 g.). Nerly ll ntibody ws removed from these mternl plsms by two bsorptions, nd from the cord plsms by one bsorption. The mternl plsm of the third cse contined low titre incomplete nti-rh nd the cord plsm of her child gve only wekly positive rection in the indirect ntiglobulin test. This infnt weighed 3459 g. nd ws born t 4 weeks' gesttion, so tht the mternl nd umbilicl cord totl IgG concentrtions were closer thn in the other two pirs (mternl concentrtion = 1489 mg./1 ml.; infnt concentrtion 1343 mg./ looml.). All ntibody ws removed from both ser by one bsorption. Results in Hemolytic Disese of the Newborn Quntittion ofproteins in mternl plsm. In 16 specimens of plsm collected t time of delivery from mothers with nti-rh ntibody titres rnging from 1 in 1 to 1 in 6 (9 being 1/4 or higher), the men concentrtion of IgG from the log vlue ws 1352 mg./1 ml. with ±2 SD rnge from 89 to 253 mg. This concentrtion is not significntly different from the men level of 139 mg./1 ml. previously found by us in 6 helthy mothers (t = *511, *7>p>*6). Quntittion of proteins in umbilicl cord O plsm. The concentrtions of lbumin, IgG, nd IgM in the umbilicl plsm of 42 ffected infnts 'c) prcticlly ll fell within the ±2 rnge found in 11 z 1 Birthweight (9. * helthy infnts (Fig., b, c). Although, in the o. / cse of IgG, nd IgM, more vlues fell below the norml men thn bove it, no significnt difference / : o o:: ws found in the mture by weight infnts between. * < * the men concentrtions of corresponding plsm o / proteins in helthy infnts nd those with hemoo,t lytic disese (Tble I). The concentrtions of lbumin nd IgG in the 42 specimens were signi- / FIG.-Albumin (), IgG (b), nd IgM (c) concentrtions in umbilicl venous plsm in 15 infnts with respirtory distress syndrome, nd 42 infnts with hemolytic 2&n 3& disese. Regression of IgG concentrtion on birth- M 4~ weight with 95% confidence limits for helthy premture infnts nd men concentrtion nd 95% confidence limits for helthy mture infnts re illustrted.

3 Immunoglobulins in Umbilicl Cord Plsm 163 TABL I Comprison of Concentrtions of Albumin, IgG, nd IgM in Umbilicl Cord Plsm of 36 Mture by Birthweight Infnts with Hemolytic Disese of Newborn nd 44 Helthy Mture by Birthweight Infnts Hemolytic Nr Disese Norml t No. of cses Men birthweight (g.) >p> 5 Men log [plsm lbumin concentrtion ( concentrtion in reference plsm)] *7>p> 6 Men log [plsm IgG concentrtion (mg./1 ml.)] >p>5 Men log [plsm IgM concentrtion (mg./1 ml.)] O5>p>4 ficntly correlted (r = 671; p < 1), s ws bsorption were corrected using this fctor. As found previously in helthy infnts. shown in Tble II, the ltertion in IgG concentr- In 4 of the infnts IgA ws not detected in the tion following bsorption rnged from -8% to umbilicl cord plsm by double diffusion in gr + 12% of the originl concentrtion. studies, indicting tht if IgA were present its concentrtion ws below 2-6 mg./1 ml. One infnt hd concentrtion of 1 mg./1 ml. nd one 46 mg./1 ml. The ltter infnt lso hd slightly Quntittion ofproteins in mternl plsm. rised level of IgM of 35 mg./1 ml. The men concentrtion of IgG in the venous plsm t time of delivery of 1 mothers whose Reltion between mternl nd infnt IgG infnts developed RDS ws (from logs) 1335 mg./ concentrtions. No significnt correltion ws 1 ml. with ±2 SD rnge from 74 to 2531 mg./ found between mternl nd cord plsm IgG 1 ml. Since the gesttion period of ll these concentrtions in ll 16 pired specimens (r = mothers ws 37 weeks or less, these results were 185, p >-1) or in the 13 mture by weight compred with the findings in group of 22 mothers infnt-mother pirs (r = 39, p > 1). of similr gesttion period who produced helthy infnts (men IgG concentrtion from logs = Absorption of nti-rh ntibodies. The 1236 mg./1 ml. ±2 SD rnge from 771 to 1982 concentrtions of lbumin nd IgG were estimted mg./1 ml.). There ws no significnt difference before nd fter bsorption of nti-rh ntibody between the results in the two groups (t = 747, from 3 mternl nd 3 umbilicl specimens s *5 >p >4). described bove. The lbumin vlues were used Comprison of the lbumin concentrtions in the s n index of dilution of the specimens occurring two groups of mothers lso showed no significnt during bsorption, nd the IgG concentrtions fter difference (men RDS concentrtion (from logs) TABL II Altertion in Plsm IgG Concentrtions Following Absorption of Anti-Rh Antibodies IgG concentrtion Titre of Before (A) Corrected Altertion Due to % Chnge Due to Incomplete Absorption (A) After Absorption for Dilution Absorption of Absorption of Specimen Anti-Rp ed) (A reference (B) (% reference (= C) (% Antibody (C)-(A) Antibody Antibody (plsm conc.) plsm conc.) reference (% reference (C-A 1) plsm conc.) plsm conc.) -A X 11 I Mternl.. 1/ * *6 +5 *3 Umbilicl.. 1/4 67*5 51* *7 + 8*4 II Mternl.. 1/6 63* 41*5 46*5-5 * -7*9 Umbilicl.. 1/ III Mternl.. 1/ Umbilicl. T.Tce 97*5 8* 68 *

4 %' of concentrtion in stndrd reference plsm, ±2 SD rnge from 4 to 92%; men norml concentrtion = 64%, ±2 SD rnge from 47 to 86%; t = -681, 6>p>5). McKy, Thom, nd Gry Quntittion of proteins in umbilicl cord plsm. As illustrted in Fig., b, nd c, the concentrtions of lbumin, IgG, nd IgM in 15 ffected infnts ll ly within the ±2 SD rnge for helthy infnts prt from one high lbumin vlue. IgA ws not detected in ny of the specimens. Discussion ven in high titre mternl serum Boursnell, Coombs, nd Rizk (1953) found only smll mounts of nti-d ntibody (5 4 mg./1 ml.), nd on the infnt's red cells Hughes-Jones, Hughes, nd Wlker (1967) estimted tht 4-18,ug. of nti-d ws present per ml. of cells, which is less thn 3 mg. for the totl circulting red cell mss of n verge helthy full-term infnt. The totl mount of IgG bsorbed on the red cells in hemolytic disese of the newborn t ny one time is therefore very smll compred to the totl IgG complement of the dult or of the full-term helthy infnt. ven llowing for rpid hemopoiesis in the ffected infnt, which my increse the utiliztion of ntibody, nd even though it is possible tht nti-rh ntibody is preferentilly trnsferred to the fetus, the mount of IgG utilized is unlikely to lower the fetl y-globulin concentrtion to the levels found by Hrdie et l. (1965) in 3 infnts with hemolytic disese of the newborn. We were unble to demonstrte ny reduction in the concentrtion of IgG in 3 specimens of mternl plsm nd 3 of umbilicl cord plsm following bsorption of nti-rh ntibody. The ntibody titres in these ser were probbly lower thn tht in the serum studied by Boursnell et l. (1953) where the totl nti-rh ntibody would constitute s little s 3- *5 % of the norml mternl IgG concentrtion. It must be remembered lso tht the error of the single rdil diffusion in gr method of quntittion pplies here to the estimtion of IgG nd lso of lbumin used to correct for dilution occurring during the bsorption. In this lbortory the coefficient of vrition for the method of estimtion is 6 * 6% for lbumin nd 5 * % for IgG. In the present series the plsm concentrtion of IgG in mothers whose infnts were ffected by hemolytic disese ws not reduced below the levels found in norml mothers, nd in the ffected infnts, though the greter proportion of the IgG concentrtions in umbilicl cord plsm fell below the norml men, the results in the two groups were not significntly different. These findings differ from results of Nejedl (1967) who found low y- globulin levels in hemolytic disese infnts, Steinberg et l. (1956) who found the infnt IgG concentrtions low reltive to the mternl concentrtion, nd Hrdie et l. (1965) who reported low concentrtions in 3 ffected infnts. In these 3 series y-globulin ws estimted by pper electrophoresis, so tht the results re not strictly comprble with the present series where individul immunoglobulins were quntitted by single rdil diffusion in gr. It is of interest tht Hrdie nd Kench (1967) found lrge discrepncy between their estimtions of y-globulin concentrtion on pper electrophoresis nd of seprte immunoglobulins by specific immunologicl methods. In norml helthy infnts close correltion exists between the concentrtions of IgG in mternl venous nd umbilicl venous plsm t delivery (Thom et l., 1967b). No significnt correltion ws found between the corresponding concentrtions for the series of hemolytic disese cses studied. The reson for this finding is not cler. It my hve been due to chnges in the mternl plsm proteins or to generl ltertion in the concentrtions of fetl plsm proteins s by hemodilution or hemoconcentrtion, since the close correltion normlly found between IgG nd lbumin concentrtions in umbilicl cord plsm ws still evident in the ffected infnts. The rised IgA concentrtions found in 2 specimens of umbilicl cord plsm re unexplined by the hemolytic disese process, nd scrutiny of the mternl cse notes reveled no history of infections or other bnormlities during the pregnncy. It is possible, however, tht rised concentrtions of IgA or IgM in umbilicl cord plsm my rise from subclinicl infection of the fetus t some stge of pregnncy. In infnts with RDS, Hrdie et l. (1965) found low concentrtions of y-globulin, nd suggested tht one possible explntion ws the opertion of n immunologicl rection with utiliztion of y- globulin in the infnt. However, ny single ntibody is unlikely to exceed 1% of the totl y-globulin nd, s shown bove for nti-rh ntibodies, even high titre of ntibodies my comprise much lower percentge. In the present series of infnts with RDS, though more of the IgG concentrtions in umbilicl cord plsm were below the norml men thn bove, they ll fell within the 2 stndrd devition rnge of norml vlues. Also, contrry to the findings of Hrdie nd Kench (1967), the IgG concentrtions in the mothers of these infnts were within norml limits for mothers of

5 helthy infnts of similr gesttion. The results in the present series neither support nor contrdict the suggestion of Mrkrin, Jckson, nd Bnnon (1966) tht the disese process begins in utero. In 196, Cooke suggested tht RDS ws ssocited with low concentrtions of totl plsm proteins in umbilicl cord blood, nd tht dministrtion of lbumin ws beneficil. Frillon nd Kitchen (1962) lso found tht the serum protein level ws relted to the development of respirtory distress, but no more closely thn ws the birthweight of the infnt, nd the totl plsm protein concentrtion of infnts normlly rises stedily with incresing birthweight. The findings of Mrkrin et l. (1966) were similr, except tht they showed some reduction in totl protein concentrtion in the umbilicl cord blood of ffected infnts prt from tht rising from birthweight effects, though the ltter were more importnt. Serum lbumin concentrtion ws lso reduced in the smller ffected infnts in the series of Hrdie et l. (1965). In the present series, where lbumin concentrtions were considered in reltion to birthweight, no difference ws found between distressed nd helthy infnts. Summry The concentrtions of IgG, IgA, IgM, nd lbumin were estimted in the umbilicl cord plsm of 42 cses of hemolytic disese of the newborn nd 15 infnts who developed respirtory distress syndrome. No differences of sttisticl significnce were found from the concentrtions present in helthy infnts. No difference ws found in the concentrtion of IgG in smples of mternl nd umbilicl cord plsm from cses of hemolytic disese of the newborn before nd fter bsorption of nti-rh ntibodies. Immunoglobulins in Umbilicl Cord Plsm 165 We re indebted to Professor R. G. Mitchell nd Professor I. McGillivry for permission to study ptients under their cre, nd to the nursing stff of the Aberdeen Mternity Hospitl for their co-opertion in the collection of blood specimens. We thnk Dr. H. Brodie M. Lewis, Regionl Director of Blood Trnsfusion Service, for crrying out the bsorption of rhesus ntiser nd for helpful discussion. RFRNCS Boursnell, J. C., Coombs, R. R. A., nd Rizk, V. (1953). Studies with mrked ntiser. Quntittive studies with ntiser mrked with iodine131 isotope nd their corresponding red-cell ntigens. Biochem. J., 55, 745. Cooke, W. D. D. (196). Prognostic significnce of the serum protein content in premture bbies nd its reltion to pulmonry hyline membrne: preliminry communiction. Med. J. Aust., 1, 887. Frillon, J. M. G., nd Kitchen, W. H. (1962). The reltionship between serum protein levels nd hyline membrne disese in premture bbies. ibid., 2, 941. Hrdie, G., Heese, H. de V., nd Kench, J.. (1965). Serumproteins in the idiopthic respirtory distress syndrome of the newborn. Lncet, 2, , nd Kench, J.. (1967). Mternl serum-proteins in idiopthic respirtory distress syndrome of the newborn. ibid., 1, 89. Hughes-Jones, N. C., Hughes, M. I. J., nd Wlker, W. (1967). The mount of nti-d on red cells in hemolytic disese of the newborn. Vox Sng. (Bsel), 12, 279. Mrkrin, M., Jckson, J. J., nd Bnnon, A.. (1966). Seril serum totl protein vlues in premture infnts with nd without the respirtory distress syndrome. J. Pedit., 69, 146. Nejedl, Z. (1967). The effect of exchnge trnsfusion on the development of immunologicl fctors. Vox Sng. (Bsel), 12, 118. Stemberg, J., Dgenis-Perusse, P., nd Dreyfuss, M. (1956). Serum proteins in prturient mother nd newborn: n electrophoretic study. Cnd. med. Ass. J., 74, 49. Thom, H., McKy,., nd Gry, D. (1967). Immunoglobulins in umbilicl cord plsm. I. Helthy infnts. Arch. Dis. Childh., 42, 259., -, nd - (1967b). Protein concentrtions in the umbilicl cord plsm of premture nd mture infnts. Clin. Sci., 33, 433. Troelstr, J. A., Jonxis, J. H. P., Visser, H. K. A., nd vn der Vlugt, J. J. (1964). Metbolism nd cid-bse regultion in respirtory distress syndrome; tretment with tris-hydroxymethyl-minomethne (THAM). In Nutrici Symposium, The Adpttion of the Newborn Infnt to xtr-uterine Life, p d. by J. H. P. Jonxis, H. K. A. Visser, nd J. A. Troelstr. H.. Stenfert Kroese, Leyden.