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Treatments that remove B cells also remove the antibodies B cells make, and some people never make them again. When repeated chest and sinus infections follow, donated antibody given monthly by drip or weekly under the skin prevents them.
B-cell aplasia is the expected consequence of CD19 CAR-T and a common one after CD20 bispecific antibodies and prolonged rituximab or obinutuzumab. IgG falls, and in a proportion of patients it stays low for years. The clinical problem is not the number but the infections: recurrent bacterial sinopulmonary infection, bronchiectasis if it goes on long enough, and severe or prolonged viral respiratory illness.
Who is offered replacement. Practice differs, and the trigger is usually a combination rather than a threshold: an IgG persistently below about 4 g per litre together with recurrent or severe bacterial infection, or documented failure to respond to test vaccination. Children after CAR-T are replaced more readily than adults. Replacement is given as intravenous immunoglobulin every three to four weeks or subcutaneous immunoglobulin weekly, which most people prefer because it can be given at home and avoids the end-of-cycle dip.
What else is done first. Measure IgG, IgA and IgM before and after B-cell-depleting treatment; give prophylactic antibiotics for recurrent infection before moving to replacement; vaccinate where a response is still possible; treat bronchiectasis actively. Immunoglobulin is a donated human product in limited supply, which is why national demand-management criteria exist in the United Kingdom and why the decision is made in a specialist clinic.
Backbone ribbon from PDB 6VJA. RCSB PDB 6VJA. The ribbon widens where the chain is folded into a regular pattern and narrows where it is a loose loop.
Showing the molecule this term concerns: Rituximab.
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