Vasculitis secondary to staphylococcal Protein A immunoadsorption (Prosorba column) treatment in rheumatoid arthritis

[Role of plasmapheresis and immunoadsorption in salvage therapy of rheumatological diseases]

Many rheumatological diseases are either caused by specific known proteins, such as antibodies or mediated by a plethora of cytokines. Both the unspecific immunosuppressive therapy and the specific action of biologics usually require time to be effective; therefore, extracorporeal forms of treatment are increasingly being employed in severe forms of rheumatological diseases as well as in patients who cannot tolerate pharmacological treatment or where the risk of pharmacological treatment may outweigh the potential benefits. Therapeutic plasma exchange (TPE) removes not only pathogenic substances, such as autoantibodies, lipoproteins and circulating immune complexes from the plasma but also cytokines. The removed plasma that is discarded has to be substituted by blood products, e.g. human albumin or fresh frozen plasma. Fresh frozen plasma is always used when missing plasma components must be replenished, such as ADAMTS-13 in thrombotic thrombocytopenic purpura (TTP). The separated plasma can be further processed by pumping into a hollow fiber filter (cut-off of ~700 kD) and in this way low-density lipoprotein cholesterol and IgM can be eliminated. This treatment mode, called cascade filtration is used to treat diseases, such as Waldenström's macroglobulinemia and cryoglobulinemia. A specific way to remove antibodies is by immunoadsorption in which the antibodies are specifically removed by an adsorber. For this procedure there is no need to substitute blood products. This review article describes the principles of the two different treatment methods, the advantages and disadvantages and also summarizes the current evidence for their use in rheumatological diseases.

Effect of Double Filtration Plasmapheresis on Various Plasma Components and Patient Safety: A Prospective Observational Cohort Study

Double filtration plasmapheresis (DFPP) was historically used for blood group incompatible renal transplantation. Very few studies are available worldwide regarding its efficiency in removing specific plasma components, and safety. We conducted a prospective observational cohort study over 1 year on patients undergoing DFPP for various renal indications. There were 15 patients with 39 sessions. The pre- and post-procedure plasma samples of serum IgG, IgA, IgM, fibrinogen, calcium, phosphate, potassium, and magnesium were analyzed. The effluent albumin concentration was also measured, and complications during the hospital stay were recorded. Cumulative removal of serum IgG, IgA, IgM, fibrinogen, and albumin at the end of four sessions were 72%, 89%, 96%, 88.5%, and 21.3%, respectively and effluent albumin concentration was 1.75 – 2.0 times (range: 6.3 g/dl – 7.2 g/dl; mean ± standard deviation (SD) – 7 g/dl ± 0.3 g/dl) the preprocedural serum albumin (mean ± SD – 3.5 g/dl ± 0.5 g/dl). Removal of other plasma components were not statistically significant. Hypotensive episodes were observed only 16.6%, with the usage of effluent concentration albumin as replacement fluid despite an average 2.4 (mean ± SD – 2.4 ± 0.4 l) liters of plasma volume processing each session. DFPP removes IgG, IgA, IgM, fibrinogen, and albumin. The cumulative removal IgG (72%) is suboptimal, whereas IgA (89%) and IgM (96%) are comparable to historical controls. We observed lesser episodes (12.5%) of hypotension with effluent albumin concentration as replacement fluid, and all bleeding complications were observed when serum fibrinogen level was <50 mg/dl.

Plasma exchange for rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common inflammatory joint disease. Even though, physiopathology of rheumatoid arthritis remains unclear, the presence of circulating immune complexes and rheumatoid factors had led to the use of plasma exchange (PE). Even though PE procedures have evolved over the last decades, their indications and use in RA must be replaced in the context of the evolution of disease-modifying anti-rheumatic drugs. Results of PE and leukapheresis were disappointing in patients with severe and resistant RA. Conversely, immunoadsorption, and particularly over a Staphylococcus aureus protein A column, has resulted in some good responses in refractory RA patients. But, the emergence of effective biologics has clearly restrained their use and limited their indications to some rare patients with refractory and severe RA.

Acute glomerulonephritis occurring during immunoadsorption with staphylococcal protein A column (Prosorba(R))

BACKGROUND

Apheresis of patient plasma by immunoadsorption with a staphylococcal protein A (SPA) column is used in a variety of autoimmune disorders. Leukocytoclastic vasculitis is an uncommon severe complication that can occur during immunoadsorption with SPA (Prosorba.

METHODS

We report a case of immune complex glomerulonephritis occurring during Prosorba immunoabsorption in a patient with rheumatoid arthritis (RA). Using a Medline literature search and information provided by Cypress Bioscience/Fresenius Hemocare, we review renal complications associated with Prosorba immunoadsorption.

RESULTS

We identified seven additional potential cases of glomerulonephritis (GN) in association with Prosorba immunoadsorption. Five of these patients were being treated for RA, and two for idiopathic thrombocytopenia purpura (ITP). Renal biopsies were performed on four patients, all of whom had evidence of immune complex GN. Among RA patients treated with Prosorba, the incidence of GN closely paralleled that of leukocytoclastic vasculitis at 1.75%. The presence of leukocytoclastic vasculitis was a significant risk factor for the development of GN (relative risk = 75.95, CI 7-1869, P = 0.00021). In contrast, among more than 10 000 ITP patients treated with Prosorba, there were only two potential cases of GN. The risk of developing GN in association with Prosorba immunoadsorption was significantly greater for patients with RA than for those with ITP (relative risk = 62.95, CI 10-453, P = 0.00002).

CONCLUSION

This case series highlights the risk of GN among patients undergoing SPA immunoadsorption. The development of GN is associated with the presence of leukocytoclastic vasculitis. Patients with RA seem to be at particular risk.