Intravenous immunoglobulin and exchange transfusion in severe iso-immune hemolytic hyperbilirubinemia: A retrospective cohort study

Objectives To assess Intravenous Immunoglobulin (IVIG) efficacy in preventing exchange transfusion (ET) in neonates with iso-immune hemolytic disease of the newborn (HDN). Study Design A retrospective data review of 22 688 neonates admitted to the NICU of Madinah Maternity and Children’s Hospital, KSA from January 2015 to January 2025 was done. Out of them, 173 neonates ≥35 weeks with HDN at risk for ET were identified based on American Academy of Pediatrics (AAP) 2022 thresholds (74 received IVIG and 99 did not). Infants were managed according to 2004 AAP guidelines. We assessed the following outcomes: rate of ET, occurrence of rebound hyperbilirubinemia, phototherapy (PT) duration, length of hospital stay, and the need for packed red blood cells (PRBC) transfusion. The association of IVIG with outcomes was adjusted to quintiles of propensity score (PS) controlling for the likelihood of receiving IVIG. Results IVIG recipients had a greater hemolytic burden (initial hemoglobin: 14.19 vs. 16.06 g/dL, p < 0.001; reticulocyte count: 11.31% vs. 8.75%, p = 0.002; positive direct antiglobulin test: 94.6% vs. 80.8%, p = 0.008). Unadjusted analyses showed that IVIG recipients, compared to the non-IVIG group, had higher ET rates (20.27% vs. 5.05%; OR 4.78 [1.65–13.84], p = 0.002), longer PT duration, extended hospital stays, and more PRBC transfusions. However, after propensity score adjustment, no significant differences were observed for ET and PRBC transfusions. Consistent differences were retained for PT and hospital stay durations. Conclusion IVIG as an adjunct to intensive PT was not associated with a statistically significant reduction in ET rates in infants with HDN.