Immunoglobulins A, D, G, and M

Synonym/acronym: IgA, IgD, IgG, and IgM.

Common use

To quantitate immunoglobulins A, D, G, and M as indicators of immune system function, to assist in the diagnosis of immune system disorders such as multiple myeloma, and to investigate transfusion anaphylaxis.

Specimen

Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Place separated serum in a standard transport tube within 2 hr of collection.

Normal findings

(Method: Nephelometry)

Age	Conventional Units	SI Units
Immunoglobulin A		(Conventional Units × 0.01)
Newborn	1–4 mg/dL	0.01–0.04 g/L
1–9 mo	2–80 mg/dL	0.02–0.8 g/L
10–12 mo	15–90 mg/dL	0.15–0.9 g/L
2–3 yr	18–150 mg/dL	0.18–1.5 g/L
4–5 yr	25–160 mg/dL	0.25–1.6 g/L
6–8 yr	35–200 mg/dL	0.35–2 g/L
9–12 yr	45–250 mg/dL	0.45–2.5 g/L
Older than 12 yr	40–350 mg/dL	0.40–3.5 g/L
Immunoglobulin D		(Conventional Units × 10)
Newborn	Greater than 2 mg/dL	Greater than 20 mg/L
Adult	Less than 15 mg/dL	Less than 150 mg/L
Immunoglobulin G		(Conventional Units × 0.01)
Newborn	650–1,600 mg/dL	6.5–16 g/L
1–9 mo	250–900 mg/dL	2.5–9 g/L
10–12 mo	290–1,070 mg/dL	2.9–10.7 g/L
2–3 yr	420–1,200 mg/dL	4.2–12 g/L
4–6 yr	460–1,240 mg/dL	4.6–12.4 g/L
Greater than 6 yr	650–1,600 mg/dL	6.5–16 g/L
Immunoglobulin M		(Conventional Units × 0.01)
Newborn	Less than 25 mg/dL	Less than 0.25 g/L
1–9 mo	20–125 mg/dL	0.2–1.25 g/L
10–12 mo	40–150 mg/dL	0.4–1.5 g/L
2–8 yr	45–200 mg/dL	0.45–2 g/L
9–12 yr	50–250 mg/dL	0.5–2.5 g/L
Greater than 12 yr	50–300 mg/dL	0.5–3 g/L

Description

Immunoglobulins A, D, E, G, and M are made by plasma cells in response to foreign substances. Immunoglobulins neutralize toxic substances, support phagocytosis, and destroy invading microorganisms. They are made up of heavy and light chains. Immunoglobulins produced by the abnormal proliferation of a single plasma cell (clone) are called monoclonal. Polyclonal increases result when multiple cell lines produce excessive amounts of antibody. IgA is found mainly in secretions such as tears, saliva, and breast milk. It is believed to protect mucous membranes from viruses and bacteria. The function of IgD is not well understood. For details on IgE, see the monograph titled “Immunoglobulin E.” IgG is the predominant serum immunoglobulin and is important in long-term defense against disease. It is the only antibody that crosses the placenta. IgM is the largest immunoglobulin, and it is the first antibody to react to an antigenic stimulus. IgM also forms natural antibodies, such as ABO blood group antibodies. The presence of IgM in cord blood is an indication of congenital infection.

This procedure is contraindicated for

N/A

Indications

Assist in the diagnosis of multiple myeloma
Evaluate humoral immunity status
Monitor therapy for multiple myeloma
IgA: Evaluate patients suspected of IgA deficiency prior to transfusion. Evaluate anaphylaxis associated with the transfusion of blood and blood products (anti-IgA antibodies may develop in patients with low levels of IgA, possibly resulting in anaphylaxis when donated blood is transfused)

Potential diagnosis

Increased in

IgA

Polyclonal
Chronic liver disease (pathophysiology is unclear)
Immunodeficiency states, such as Wiskott-Aldrich syndrome (inherited condition of lymphocytes characterized by increased IgA and IgE)
Inflammatory bowel disease (IgG and/or IgA antibody positive for Saccharomyces cerevisiae with negative perinuclear-antineutrophil cytoplasmic antibody is indicative of Crohn’s disease)
Lower gastrointestinal (GI) cancer (pathophysiology is unclear)
Rheumatoid arthritis (pathophysiology is unclear)
Monoclonal
IgA-type multiple myeloma (related to excessive production by a single clone of plasma cells)

IgD

Polyclonal (pathophysiology is unclear, but increases are associated with increases in IgM)
Certain liver diseases
Chronic infections
Connective tissue disorders
Monoclonal
IgD-type multiple myeloma (related to excessive production by a single clone of plasma cells)

IgG

(Conditions that involve inflammation and/or development of an infection stimulate production of IgG.)
Polyclonal
Autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren’s syndrome
Chronic liver disease
Chronic or recurrent infections
Intrauterine devices (the IUD creates a localized inflammatory reaction that stimulates production of IgG)
Sarcoidosis
Monoclonal
IgG-type multiple myeloma (related to excessive production by a single clone of plasma cells)
Leukemias
Lymphomas

IgM

Polyclonal (humoral response to infections and inflammation; both acute and chronic)
Active sarcoidosis
Chronic hepatocellular disease
Collagen vascular disease
Early response to bacterial or parasitic infection
Hyper-IgM dysgammaglobulinemia
Rheumatoid arthritis
Variable in nephrotic syndrome
Viral infection (hepatitis or mononucleosis)
Monoclonal
Cold agglutinin hemolysis disease
Malignant lymphoma
Neoplasms (especially in GI tract)
Reticulosis
Waldenström’s macroglobulinemia (related to excessive production by a single clone of plasma cells)

Decreased in

IgA

IgD

IgG

IgM

Critical findings

N/A

Interfering factors

Drugs that may increase immunoglobulin levels include asparaginase, cimetidine, and narcotics.
Drugs that may decrease immunoglobulin levels include dextran, oral contraceptives, methylprednisolone (high doses), and phenytoin.
Chemotherapy, immunosuppressive therapy, and radiation treatments decrease immunoglobulin levels.
Specimens with macroglobulins, cryoglobulins, or cold agglutinins tested at cold temperatures may give falsely low values.

Nursing Implications and Procedure

Potential nursing problems

Problem	Signs & Symptoms	Interventions
Hopelessness (Related to chronic illness; impaired functionality; prolonged pain and discomfort)	Decreased affect; decreased response to stimuli; feeling of emptiness; alterations in sleep patterns and appetite; expressions of apathy; withdrawn; states life has no meaning	Assess role of illness in relation to expressions of helplessness; assess grooming (energy to provide good personal hygiene); assess level of appetite; assess verbalization of helplessness; provide opportunities to express feelings in a safe environment; support development of a trusting relationship to decrease feelings of isolation; encourage verbalization of personal strengths and weaknesses; encourage realistic hope; assist in identification of coping skills
Protection (Related to failure of bone marrow; replacement of bone marrow by neoplastic cells; insufficient autoimmune response; chemotherapy; bone marrow transplant)	Bleeding; infection; anemia	Monitor and trend HGB/HCT; monitor and trend platelets and red blood cells (RBCs); monitor for symptoms of infection; take temperature every 4 hr; institute bleeding precautions, soft toothbrushes, avoid aspirin, avoid IM or IV injections, coordinate laboratory draws to minimize venipuncture; administer prescribed steroids, erythropoietin; administer prescribed blood and blood products; avoid at-risk activities that could cause trauma; discuss exposure to microbes that could result in infection
Pain (Related to invasion of bone marrow and pathological fractures secondary to medication diagnosis [multiple myeloma])	Self-report of pain; guarding; crying; moaning; sleeplessness; restlessness; emotional symptoms of distress; agitation; facial grimace; rocking motions; irritability; diaphoresis; altered blood pressure and heart rate; nausea; vomiting	Assess pain characteristics, skeletal pain, low back, ribs; assess level of pain with movement; identify pain modalities that have relieved pain in the past; administer prescribed pain medication; monitor and trend vital signs; recommend use of nonpharmacologic pain management modalities, imagery, distraction, music, relaxation, correct body alignment

Pretest

Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
Patient Teaching: Inform the patient this test can assess the immune system by evaluating the levels of immunoglobulins in the blood.
Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
Obtain a history of the patient’s hematopoietic and immune systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
Note any recent procedures that can interfere with test results.
Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain to the patient that there may be some discomfort during the venipuncture.
Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

Potential complications: N/A
Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.
Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture.
Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.
Promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient. A patient with IgA deficiency should not receive gamma globulin. Administration of gamma globulin may initiate sensitization of the immune system that could result in an anaphylactic shock during a subsequent RBC product transfusion, related to instigation by donor IgA in the product. IgA deficiency is a lifelong condition, if transfusion is necessary and products from an IgA-deficient donor are unavailable, washed RBCs can be used to decrease the risk of transfusion reaction.
Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
Patient Education
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
- Answer any questions or address any concerns voiced by the patient or family.
- Provide information on the disease process as it relates to altered laboratory results.
Expected Patient Outcomes
- Knowledge
- States understanding of the importance of notifying the HCP if the pain management regime is ineffective
- States understanding that a combination of pain management modalities may be most effective in managing pain
- Skills
- Describes appropriate use of pain scale for quantifying the severity of pain experienced
- Demonstrates proficiency in using a selected nonpharmacological pain management strategy to decrease pain intensity
- Attitude
- Complies with the recommendation to try using nonpharmacological measures to decrease pain
- Complies with the recommendation to take pain medication around the clock to decrease the risk of peak pain periods

Related Monographs

Related tests include ALT, anion gap, ANA, bilirubin, biopsy bone, biopsy bone marrow, biopsy liver, biopsy lymph node, blood groups and antibodies, cold agglutinin, CBC, CBC WBC count and differential, Coomb’s antiglobulin (direct and indirect), cryoglobulin, ESR, fibrinogen, IFE, quantitative immunoglobulin levels, GGT, LAP, liver and spleen scan, beta-2-microglobulin, platelet antibodies, protein total and fractions, RF, and uric acid.
Refer to the Hematopoietic and Immune systems tables at the end of the book for related tests by body system.

Immunoglobulins A, D, G, and M