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Fousse M, Fassbender K, Schunk SJ, Schmidt T, Stögbauer J. Apheresis treatment in autoimmune neurological diseases: Predictors of good clinical outcome and success of follow-up therapy with B-cell depletion. J Neurol Sci 2024; 461:123050. [PMID: 38768532 DOI: 10.1016/j.jns.2024.123050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/14/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE Apheresis treatment (AT) is an established standard of treatment in various neurological autoimmune diseases. Since not all patients equally benefit from AT, we saw the need to investigate the effect of different clinical, paraclinical and technical-apparative factors on the clinical outcome. Additionally, we wanted to find out whether patients who improved due to AT continue to be clinically stable under B-cell depletion (BCD). METHODS We screened all patients (n = 358) with neurological diseases who received AT at the Medical center of the University of the Saarland in the past 20 years. Different factors (e.g., age, sex, duration until onset of AT, type of AT, number of cycles, csf parameters) were analyzed retrospectively. Clinical disability was measured using the modified Rankin scale (mRS), visual acuity and the Expanded Disability Status Scale (EDSS). RESULTS 335 patients, categorized into 11 different autoimmune diagnosis groups, received a total of 2669 treatment cycles and showed a statistically significant improvement in mRS with AT (p < 0.001). Patients in American Society for Apheresis (ASFA) categories I (p = 0.013) and II (p = 0.035) showed a significantly greater benefit under AT than those in category III. The clinical outcome was better with shorter duration until AT onset, more cycles of AT, and more plasma volume exchanged and the presence of an autoimmune antibody. Patients who initially profited had a significantly more stable course of the disease after 1-Year-BCD (p = 0.039). DISCUSSION In the present study, we were able to identify various significant factors influencing the outcome of patients due to AT. Furthermore, we could show that patients with a response to AT can benefit from BCD follow-up therapy.
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Affiliation(s)
- Mathias Fousse
- Department of Neurology, Saarland University Medical Center, 66421 Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, 66421 Homburg, Germany
| | - Stefan J Schunk
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, 66421 Homburg, Germany
| | - Tina Schmidt
- Department of Transplant and Infection Immunology, Saarland University, 66421 Homburg, Germany
| | - Jakob Stögbauer
- Department of Neurology, Saarland University Medical Center, 66421 Homburg, Germany.
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Querol L, De Sèze J, Dysgaard T, Levine T, Rao TH, Rivner M, Hartung HP, Kiessling P, Shimizu S, Marmol D, Bozorg A, Colson AO, Massow U, Eftimov F. Efficacy, safety and tolerability of rozanolixizumab in patients with chronic inflammatory demyelinating polyradiculoneuropathy: a randomised, subject-blind, investigator-blind, placebo-controlled, phase 2a trial and open-label extension study. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333112. [PMID: 38729747 DOI: 10.1136/jnnp-2023-333112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/13/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a peripheral nerve disorder characterised by weakness and sensory loss. We assessed the neonatal Fc receptor inhibitor rozanolixizumab for CIDP management. METHODS CIDP01 (NCT03861481) was a randomised, subject-blind, investigator-blind, placebo-controlled, phase 2a study. Adults with definite or probable CIDP receiving subcutaneous or intravenous immunoglobulin maintenance therapy were randomised 1:1 to 12 once-weekly subcutaneous infusions of rozanolixizumab 10 mg/kg or placebo, stratified according to previous immunoglobulin administration route. Investigators administering treatment and assessing efficacy, and patients, were blinded. The primary outcome was a change from baseline (CFB) to day 85 in inflammatory Rasch-built Overall Disability Scale (iRODS) score. Eligible patients who completed CIDP01 entered the open-label extension CIDP04 (NCT04051944). RESULTS In CIDP01, between 26 March 2019 and 31 March 2021, 34 patients were randomised to rozanolixizumab or placebo (17 (50%) each). No significant difference in CFB to day 85 in iRODS centile score was observed between rozanolixizumab (least squares mean 2.0 (SE 3.2)) and placebo (3.4 (2.6); difference -1.5 (90% CI -7.5 to 4.5)). Overall, 14 (82%) patients receiving rozanolixizumab and 13 (76%) receiving placebo experienced a treatment-emergent adverse event during the treatment period. Across CIDP01 and CIDP04, rozanolixizumab was well tolerated over up to 614 days; no clinically meaningful efficacy results were seen. No deaths occurred. CONCLUSIONS Rozanolixizumab did not show efficacy in patients with CIDP in this study, although this could be due to a relatively high placebo stability rate. Rozanolixizumab was well tolerated over medium-to-long-term weekly use, with an acceptable safety profile.
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Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit - Neurology Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
- Center for Network Research in Rare Diseases - CIBERER, Madrid, Spain
| | - Jérôme De Sèze
- Department of Neurology, Clinical Investigation Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Tina Dysgaard
- Department of Neurology, Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Todd Levine
- Honor Health Neurology, Bob Bové Neuroscience Institute, Scottsdale, Arizona, USA
| | - T Hemanth Rao
- The Neurological Institute, PA, Charlotte, North Carolina, USA
| | - Michael Rivner
- Department of Neurology, Augusta University, Augusta, Atlanta, Georgia, USA
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- Brain and Mind Center, Medical Faculty, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Palacký University, Olomouc, Czech Republic
| | | | | | | | - Ali Bozorg
- UCB Pharma, Morrisville, North Carolina, USA
| | | | | | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Heigl F, Hettich R, Fassbender C, Klingel R, Mauch E, Durner J, Kern R, Kleiter I. Immunoadsorption as maintenance therapy for refractory neuromyelitis optica spectrum disorder. Ther Adv Neurol Disord 2023; 16:17562864221150314. [PMID: 36762319 PMCID: PMC9905021 DOI: 10.1177/17562864221150314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/12/2022] [Indexed: 02/10/2023] Open
Abstract
Background Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing autoimmune disease of the central nervous system, affecting mainly optic nerves and spinal cord. NMOSD pathophysiology is associated with anti-aquaporin-4 (AQP4) immunoglobulin G (IgG) autoantibodies. Rapid extracorporeal elimination of autoantibodies with apheresis techniques, such as immunoadsorption (IA), was proven to be an effective treatment of NMOSD attacks. Data on the long-term use of IA to prevent attacks or progression of NMOSD are lacking. Objectives The aim of this study was to evaluate efficacy and safety of maintenance IA for preventing recurrence of NMOSD attacks in patients refractory to other immunotherapies. Design Case study. Methods Retrospective analysis of two female patients with severe NMOSD refractory to conventional immunotherapies was performed. Both patients had responded to tryptophan IA (Tr-IA) as attack therapy and subsequently were treated with biweekly maintenance Tr-IA. Results Patient 1 (AQP4-IgG seropositive, age 42 years) had 1.38 attacks of optic neuritis per year within 10.1 years before commencing regular Tr-IA. With maintenance Tr-IA for 3.1 years, one mild attack occurred, which was responsive to steroid pulse therapy. Expanded Disability Status Scale (EDSS) was stable at 5.0. Visual function score of the last eye improved from 3 to 1. Patient 2 (AQP4-IgG seronegative, age 43 years) experienced 1.7 attacks per year, mainly acute myelitis and optic neuritis, during the period of 10.0 years before the start of Tr-IA. During regular Tr-IA treatment, no further NMOSD attack occurred. The patient was clinically stable without any additional immunosuppressive treatment for 5.3 years. EDSS improved from 6.0 to 5.0, and the ambulation score from 7 to 1. Tolerability of Tr-IA was good in both patients. No serious adverse events occurred during long-term clinical trajectories. Conclusion Tr-IA was well tolerated as maintenance treatment and resulted in clinical stabilization of two patients with highly active NMOSD, who were refractory to standard drug therapy.
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Affiliation(s)
- Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | | | | | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany; 1st Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erich Mauch
- Clinic for Neurology Dietenbronn, Academic Hospital of University of Ulm, Schwendi, Germany
| | - Joachim Durner
- Neurology Department, M&I Fachklinik Ichenhausen, Ichenhausen, Germany
| | - Rolf Kern
- Department of Neurology, Klinikum Worms, Worms, Germany
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Liu L, Chen J, Zhang Y, Wu J, Hu J, Lin Z. Case report: Immunoadsorption therapy for anti-caspr1 antibody-associated nodopathy. Front Immunol 2022; 13:986018. [PMID: 36211443 PMCID: PMC9532626 DOI: 10.3389/fimmu.2022.986018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectives Several autoantibodies against proteins located at the node of Ranvier has been identified in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) in the last few years. Then a new concept, autoimmune nodo-paranodopathies was proposed. Cases of Caspr1 autoantibodies are the most rare. Here we describe an anti-Caspr1 nodopathy patient, summarized his clinical, physiological and pathological features. Case presentation We present the case of a 56-year-old male patient with proprioceptive loss, ataxia, coarse tremor and distal limb weakness without any painess and cranial involvement. Electrophysiological studies showed prolonged distal motor latencies, conduction slowing and reduced amplitude distal compound muscle action potential (CMAP) amplitude. Antibodies against the nodes of Ranvier in serum samples revealed a positive finding for the anti-Caspr1 antibody (1:10).Myelinated fiber loss could be revealed in nerve biopsy. Longitudinal ultrathin sections of the nodal region was discovered in electron microscope, the paranodal/nodal architecture was destructed. It was lack of transverse bands and enlargement of the space between the axon and the paranodal loops was seen. The patient improved obviously after three times immunoadsorption(IA) therapy. Conclusion Anti-Caspr1 nodopathy patient may present atypical symptoms without any neuropathic pain and cranial palsy. The destruction of paranodal/nodal architecture could be observed in nerve biopsy, which may be caused by the lost of axoglial complex formed by NF155, CNTN1 and Caspr1. Antibodies detection is important for the diagnosis, while IA therapy could be regarded as an option for the patients allergic to rituximab (RTX).
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Affiliation(s)
- Lili Liu
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Juanjuan Chen
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
- *Correspondence: Juanjuan Chen,
| | - Yue Zhang
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Jun Wu
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Jun Hu
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhijian Lin
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
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Svačina MKR, Lehmann HC. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): Current Therapies and Future Approaches. Curr Pharm Des 2022; 28:854-862. [PMID: 35339172 DOI: 10.2174/1381612828666220325102840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/08/2022] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated polyradiculoneuropathy leading to disability via inflammatory demyelination of peripheral nerves. Various therapeutic approaches with different mechanisms of action are established for the treatment of CIDP. Of those, corticosteroids, intravenous or subcutaneous immunoglobulin, or plasma exchange are established first-line therapies as suggested by the recently revised EAN/PNS guidelines for the management of CIDP. In special cases, immunosuppressants or rituximab may be used. Novel therapeutic approaches currently undergoing clinical studies include molecules or monoclonal antibodies interacting with Fc receptors on immune cells to alleviate immune-mediated neuronal damage. Despite various established therapies and the current development of novel therapeutics, treatment of CIDP remains challenging due to an inter-individually heterogeneous disease course and the lack of surrogate parameters to predict the risk of clinical deterioration.
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Affiliation(s)
- Martin K R Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Helmar C Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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Hu Y, Yang H, Fu S, Wu J. Therapeutic Plasma Exchange: For Cancer Patients. Cancer Manag Res 2022; 14:411-425. [PMID: 35140519 PMCID: PMC8818550 DOI: 10.2147/cmar.s340472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/25/2021] [Indexed: 11/23/2022] Open
Abstract
Therapeutic plasma exchange is used as a trial method for the treatment of cancer patients. Therapeutic plasma exchange uses in vitro technology to remove pathogenic factors in the plasma, returning the replacement and remaining components to the patient to facilitate cure. In the effort to explore new methods of cancer treatment, the introduction of therapeutic plasma exchange brings new hope for cancer treatment; however, the current evidence supporting therapeutic plasma exchange is controversial, and most of the evidence comes from observational studies, lacking large prospective randomized trials. Therefore, this review attempts to focus on the main indications of therapeutic plasma exchange for the treatment of tumors and their complications, including hematological tumors (multiple myeloma cast nephropathy and hyperviscosity syndrome), nervous system tumors (myasthenia gravis associated with thymoma, paraneoplastic neurological syndrome, Lambert–Eaton myasthenia syndrome, and anti-N-methyl-D-aspartate receptor encephalitis), overdose of chemotherapy drugs. In addition, the issues of side-effects and safety in the use of therapeutic plasma exchange are also discussed. However, well-designed prospective trials are needed to better define the role of therapeutic plasma exchange in cancer.
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Affiliation(s)
- Yuru Hu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Hanshan Yang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Shaozhi Fu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Jingbo Wu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, People’s Republic of China
- Correspondence: Jingbo Wu; Shaozhi Fu, Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, People’s Republic of China, Tel +8613980257136, Email ;
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7
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Potential therapeutic strategies in chronic inflammatory demyelinating polyradiculoneuropathy. Clin Exp Rheumatol 2022; 21:103032. [PMID: 34999243 DOI: 10.1016/j.autrev.2022.103032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/01/2022] [Indexed: 11/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune neuropathy involving peripheral nerve and nerve roots. The pathological hallmark of CIDP is macrophage-induced demyelination. Antibodies against nerve fibers, complement decomposition, abnormalities in plasma and cerebrospinal fluid cytokine profile, and changes of peripheral blood cell proportion were also reported in CIDP patients. These findings in immunopathology provide support for the introduction of potential therapeutic options for the treatment of CIDP. In this review, we systematically listed the potential therapeutic strategies targeting different components of the immune system by comparing the treatment of other autoimmune inflammatory diseases of the nervous system. Several ongoing clinical trials will assess the efficacy and safety of potential CIDP treatments.
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8
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Jacob S, Mazibrada G, Irani SR, Jacob A, Yudina A. The Role of Plasma Exchange in the Treatment of Refractory Autoimmune Neurological Diseases: a Narrative Review. J Neuroimmune Pharmacol 2021; 16:806-817. [PMID: 34599742 PMCID: PMC8714620 DOI: 10.1007/s11481-021-10004-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
Autoimmune neurological disorders are commonly treated with immunosuppressive therapy. In patients with refractory conditions, standard immunosuppression is often insufficient for complete recovery or to prevent relapses. These patients rely on other treatments to manage their disease. While treatment of refractory cases differs between diseases, intravenous immunoglobulin, plasma exchange (PLEX), and immune-modulating treatments are commonly used. In this review, we focus on five autoimmune neurological disorders that were the themes of the 2018 Midlands Neurological Society meeting on PLEX in refractory neurology: Autoimmune Encephalitis (AE), Multiple Sclerosis (MS), Neuromyelitis Optica Spectrum disorders (NMOSD), Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) and Myasthenia Gravis (MG). The diagnosis of inflammatory neuropathies is often challenging, and while PLEX can be very effective in refractory autoimmune diseases, its ineffectiveness can be confounded by misdiagnosis. One example is POEMS syndrome (characterized by Polyneuropathy Organomegaly, Endocrinopathy, Myeloma protein, Skin changes), which is often wrongly diagnosed as CIDP; and while CIDP responds well to PLEX, POEMS does not. Accurate diagnosis is therefore essential. Success rates can also differ within 'one' disease: e.g. response rates to PLEX are considerably higher in refractory relapsing remitting MS compared to primary or secondary progressive MS. When sufficient efforts are made to correctly pinpoint the diagnosis along with the type and subtype of refractory autoimmune disease, PLEX and other immunotherapies can play a valuable role in the patient management.
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Affiliation(s)
- Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom. .,Department of Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
| | - Gordon Mazibrada
- Department of Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, NMO Service, Liverpool, United Kingdom.,Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Fuchs K, Rummler S, Ries W, Helmschrott M, Selbach J, Ernst F, Morath C, Gauly A, Atiye S, Stauss-Grabo M, Giefer M. Performance, clinical effectiveness, and safety of immunoadsorption in a wide range of indications. Ther Apher Dial 2021; 26:229-241. [PMID: 33914397 PMCID: PMC9291474 DOI: 10.1111/1744-9987.13663] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022]
Abstract
Immunoadsorption is well known to selectively remove immunoglobulins and immune complexes from plasma and is applied in a variety of autoimmune diseases and for desensitization before, or at acute rejection after organ transplantation. Performance, safety, and clinical effectiveness of immunoadsorption were the aim of this study. This prospective, noninterventional, multicentre cohort study included patients treated with immunoadsorption (Immunosorba or GLOBAFFIN adsorbers) for any indication. Clinical effectiveness was assessed after termination of the patient's individual treatment schedule. Eighty‐one patients were included, 69 were treated with Immunosorba, 11 with GLOBAFFIN, one patient with both adsorbers. A majority of patients was treated for neurological indications, dilated cardiomyopathy, and before or after kidney or heart transplantation. Mean IgG reduction from pre‐ to post‐treatment was 69.9% ± 11.5% for Immunosorba and 74.1% ± 5.0% for GLOBAFFIN, respectively. The overall IgG reduction over a complete treatment block was 68%–93% with Immunosorba and 62%–90% with GLOBAFFIN depending on the duration of the overall treatment. After termination of the immunoadsorption therapy, an improvement of clinical status was observed in 63.0%, stabilization of symptoms in 29.6%, and a deterioration in 4.9% of patients. Changes in fibrinogen, thrombocytes, and albumin were mostly classified as noncritical. Overall, the treatments were well tolerated. Immunoadsorption in routine clinical practice with both GLOBAFFIN and Immunosorba has been safely performed, was well tolerated by patients, and effective in lowering immunoglobulins with an improvement or maintenance of clinical status, thus represents an additional therapeutic option for therapy refractory immune disorders.
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Affiliation(s)
- Kornelius Fuchs
- Department of Neurology, University Hospital, Regensburg, Germany
| | - Silke Rummler
- Institute for Transfusion Medicine, University Hospital, Jena, Germany
| | - Wolfgang Ries
- Internal Medicine, Department of Nephrology, Diakonissenkrankenhaus, Flensburg, Germany
| | | | - Jochen Selbach
- Department of Nephrology, Caritas Hospital, Bad Mergentheim, Germany
| | | | - Christian Morath
- Department for Dialysis, Nierenzentrum Heidelberg, Heidelberg, Germany
| | - Adelheid Gauly
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Saynab Atiye
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | | | - Mareike Giefer
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
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10
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Malik A, Berry R, Fung BM, Tabibian JH. Association between chronic inflammatory demyelinating polyneuropathy and gastrointestinal malignancies. Clin J Gastroenterol 2020; 14:1-13. [PMID: 33146871 DOI: 10.1007/s12328-020-01281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon and under-recognized immune-mediated disorder of the peripheral nervous system. It is associated with both infectious and non-infectious etiologies and presents in several variant forms. In rare instances, CIDP has been reported in association with gastrointestinal (esophageal, hepatic, colorectal, and pancreatic) malignancies. The diagnosis of malignancy is typically preceded by weeks to months by that of CIDP, though the inverse may also be seen. As with other etiologies of CIDP, cases associated with gastrointestinal malignancies are often treated with corticosteroids, intravenous immunoglobulins, and/or plasma exchange, with improvement or resolution of neurological symptoms in the majority of cases. In this review, we provide a practical overview of CIDP, with an emphasis on recognizing the clinical association between CIDP and gastrointestinal malignancies.
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Affiliation(s)
- Adnan Malik
- Division of Hepatology, Loyola University Medical Center, Maywood, IL, USA
| | - Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Brian M Fung
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA, 2B-182, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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11
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Peter HH, Ochs HD, Cunningham-Rundles C, Vinh DC, Kiessling P, Greve B, Jolles S. Targeting FcRn for immunomodulation: Benefits, risks, and practical considerations. J Allergy Clin Immunol 2020; 146:479-491.e5. [PMID: 32896308 PMCID: PMC7471860 DOI: 10.1016/j.jaci.2020.07.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The neonatal fragment crystallizable (Fc) receptor (FcRn) functions as a recycling mechanism to prevent degradation and extend the half-life of IgG and albumin in the circulation. Several FcRn inhibitors selectively targeting IgG recycling are now moving rapidly toward clinical practice in neurology and hematology. These molecules accelerate the destruction of IgG, reducing pathogenic IgG and IgG immune complexes, with no anticipated effects on IgA, IgM, IgE, complement, plasma cells, B cells, or other cells of the innate or adaptive immune systems. FcRn inhibitors have potential for future use in a much wider variety of antibody-mediated autoimmune diseases. Given the imminent clinical use, potential for broader utility, and novel mechanism of action of FcRn inhibitors, here we review data from 4 main sources: (a) currently available activity, safety, and mechanism-of-action data from clinical trials of FcRn inhibitors; (b) other procedures and treatments that also remove IgG (plasma donation, plasma exchange, immunoadsorption); (c) diseases resulting in loss of IgG; and (d) primary immunodeficiencies with potential mechanistic similarities to those induced by FcRn inhibitors. These data have been evaluated to provide practical considerations for the assessment, monitoring, and reduction of any potential infection risk associated with FcRn inhibition, in addition to highlighting areas for future research.
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Affiliation(s)
- Hans-Hartmut Peter
- Freiburg University Hospital, Centre for Chronic Immunodeficiency, Freiburg, Germany
| | - Hans D Ochs
- Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics, University of Washington, Seattle, Wash
| | | | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine and Department of Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada; Infectious Diseases & Immunity in Global Health Program, Research Institute-McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom.
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Davies AJ, Fehmi J, Senel M, Tumani H, Dorst J, Rinaldi S. Immunoadsorption and Plasma Exchange in Seropositive and Seronegative Immune-Mediated Neuropathies. J Clin Med 2020; 9:jcm9072025. [PMID: 32605107 PMCID: PMC7409112 DOI: 10.3390/jcm9072025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/15/2020] [Accepted: 06/24/2020] [Indexed: 12/23/2022] Open
Abstract
The inflammatory neuropathies are disabling conditions with diverse immunological mechanisms. In some, a pathogenic role for immunoglobulin G (IgG)-class autoantibodies is increasingly appreciated, and immunoadsorption (IA) may therefore be a useful therapeutic option. We reviewed the use of and response to IA or plasma exchange (PLEx) in a cohort of 41 patients with nodal/paranodal antibodies identified from a total of 573 individuals with suspected inflammatory neuropathies during the course of routine diagnostic testing (PNAb cohort). 20 patients had been treated with PLEx and 4 with IA. Following a global but subjective evaluation by their treating clinicians, none of these patients were judged to have had a good response to either of these treatment modalities. Sequential serology of one PNAb+ case suggests prolonged suppression of antibody levels with frequent apheresis cycles or adjuvant therapies, may be required for effective treatment. We further retrospectively evaluated the serological status of 40 patients with either Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP), and a control group of 20 patients with clinically-isolated syndrome/multiple sclerosis (CIS/MS), who had all been treated with IgG-depleting IA (IA cohort). 32 of these patients (8/20 with CIDP, 13/20 with GBS, 11/20 with MS) were judged responsive to apheresis despite none of the serum samples from this cohort testing positive for IgG antibodies against glycolipids or nodal/paranodal cell-adhesion molecules. Although negative on antigen specific assays, three patients’ pre-treatment sera and eluates were reactive against different components of myelinating co-cultures. In summary, preliminary evidence suggests that GBS/CIDP patients without detectable IgG antibodies on routine diagnostic tests may nevertheless benefit from IA, and that an unbiased screening approach using myelinating co-cultures may assist in the detection of further autoantibodies which remain to be identified in such patients.
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Affiliation(s)
- Alexander J. Davies
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK; (A.J.D.); (J.F.)
| | - Janev Fehmi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK; (A.J.D.); (J.F.)
| | - Makbule Senel
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (M.S.); (H.T.); (J.D.)
| | - Hayrettin Tumani
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (M.S.); (H.T.); (J.D.)
| | - Johannes Dorst
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (M.S.); (H.T.); (J.D.)
| | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK; (A.J.D.); (J.F.)
- Correspondence:
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 747] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Therapeutic Plasma Exchange in Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Presse Med 2019; 48:338-346. [PMID: 31679897 DOI: 10.1016/j.lpm.2019.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/05/2019] [Indexed: 12/28/2022] Open
Abstract
Therapeutic plasma exchange (TPE) has been used as a treatment modality in many autoimmune disorders, including neurological conditions, such as Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The American Society for Apheresis (ASFA) publishes its guidelines on the use of therapeutic apheresis every 3 years based on published evidence to assist physicians with both the medical and technical aspects of apheresis consults. The ASFA Guidelines included the use of TPE in both GBS and CIDP as an acceptable first-line therapy, either alone and/or in conjunction with other therapeutic modalities. In this article, we briefly reviewed GBS and CIDP, discussed the role of apheresis in these conditions as well as various technical aspects of the TPE procedure, such as apheresis calculation, number of volume exchange, replacement fluid, and management of potential complications.
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Short-term and long-term effects of immunoadsorption in refractory chronic inflammatory demyelinating polyneuropathy: a prospective study in 17 patients. J Neurol 2018; 265:2906-2915. [DOI: 10.1007/s00415-018-9082-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 12/25/2022]
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Tselmin S, Julius U, Bornstein SR, Hohenstein B. Low rate of infectious complications following immunoadsorption therapy without regular substitution of intravenous immunoglobulins. ATHEROSCLEROSIS SUPP 2017; 30:278-282. [PMID: 29096850 DOI: 10.1016/j.atherosclerosissup.2017.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Immunoadsorption (IA) is increasingly used instead of plasma exchange due to lower risk of side effects and a higher selectivity. As a consequence of the reduction of immunoglobulins (Ig), the rate of infectious complications might increase in those patients. We therefore aimed to investigate the infection rate following IA without intravenous IG (IVIG) substitution in our apheresis center, where patients do not receive IVIG on a regular basis. MATERIAL AND METHODS We conducted a retrospective analysis of the IA treatments performed between 2010 and 2015 without IVIG substitution and collected data on patient age, diagnosis, number of IA treatments, serum levels of Ig, total protein, albumin, C-reactive protein (CRP) and infectious complications that occurred within 2 months after the IA treatment cycle. RESULTS A total number of 52 patients (27 females) received at least 5 IA sessions using the following adsorbers: TheraSorb™-Ig (n = 3), TheraSorb™-Ig flex (n = 44), TheraSorb™ Ig pro (n = 1) and TheraSorb™-IgE (n = 5). The median number of treatment sessions was 8.8 [range 5-16], the median IgG reduction was 82 [11-99] %. Serum albumin was decreased by 8%. The median CRP levels remained normal until the end of therapy and within 2 months after that (3.10 and 4.30 mg/L respectively). Only 4 patients had infections (7.7%). Three of them received additional immunosuppressive therapy. CONCLUSIONS Immunoadsorption leads to a significant reduction of IgG. CRP as inflammatory marker is not affected. Even without substitution of IVIG the complication rate directly linked with IA is low and questionable.
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Affiliation(s)
- Sergey Tselmin
- Extracorporeal Treatment and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Ulrich Julius
- Extracorporeal Treatment and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Stefan R Bornstein
- Extracorporeal Treatment and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Bernd Hohenstein
- Extracorporeal Treatment and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Lieker I, Slowinski T, Harms L, Hahn K, Klehmet J. A prospective study comparing tryptophan immunoadsorption with therapeutic plasma exchange for the treatment of chronic inflammatory demyelinating polyneuropathy*. J Clin Apher 2017; 32:486-493. [DOI: 10.1002/jca.21546] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Ina Lieker
- Department of Nephrology; Charité University Medicine; Berlin Germany
| | - Torsten Slowinski
- Department of Nephrology; Charité University Medicine; Berlin Germany
| | - Lutz Harms
- Department of Neurology; Charité University Medicine; Berlin Germany
| | - Katrin Hahn
- Department of Neurology; Charité University Medicine; Berlin Germany
| | - Juliane Klehmet
- Department of Neurology; Charité University Medicine; Berlin Germany
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Mathis S, Vallat JM, Magy L. Novel immunotherapeutic strategies in chronic inflammatory demyelinating polyneuropathy. Immunotherapy 2016; 8:165-78. [PMID: 26809024 DOI: 10.2217/imt.15.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic immune-mediated neuropathy: it is clinically heterogeneous (relapsing-remitting form, chronic progressive form, monophasic form or CIDP having a Guillain-Barré syndrome-like onset), but potentially treatable. Although its pathophysiology remains largely unknown, CIDP is considered an immune-mediated neuropathy. Therefore, many immunotherapies have been proposed in this peripheral nervous system disorder, the most known efficient treatments being intravenous immunoglobulin, corticosteroids and plasma exchange. However, these therapies remain unsatisfactory for many patients, so numerous other immunotherapeutic strategies have been evaluated, based on their immunosuppressant or immunomodulatory potency. We have performed a large review of the literature about treatment in CIDP, with a special emphasis on novel and alternative immunotherapeutic strategies.
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Affiliation(s)
- Stéphane Mathis
- Department of Neurology, University Hospital of Poitiers, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Jean-Michel Vallat
- Department of Neurology, Centre de Référence "Neuropathies Périphériques Rares", University Hospital of Limoges, 2 Avenue Martin Luther King, 87042 Limoges, France
| | - Laurent Magy
- Department of Neurology, Centre de Référence "Neuropathies Périphériques Rares", University Hospital of Limoges, 2 Avenue Martin Luther King, 87042 Limoges, France
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Biesenbach P, Eskandary F, Ay C, Wiegele M, Derfler K, Schaden E, Haslacher H, Oberbauer R, Böhmig GA. Effect of combined treatment with immunoadsorption and membrane filtration on plasma coagulation-Results of a randomized controlled crossover study. J Clin Apher 2015; 31:29-37. [DOI: 10.1002/jca.21399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 03/22/2015] [Accepted: 04/06/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Peter Biesenbach
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University of Vienna; Vienna Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University of Vienna; Vienna Austria
| | - Cihan Ay
- Division of Hematology and Hemostaseology; Department of Medicine I; Medical University Vienna; Vienna Austria
| | - Marion Wiegele
- Department of Anaesthesia; General Intensive Care and Pain Control, Medical University Vienna; Vienna Austria
| | - Kurt Derfler
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University of Vienna; Vienna Austria
| | - Eva Schaden
- Department of Anaesthesia; General Intensive Care and Pain Control, Medical University Vienna; Vienna Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine; Medical University of Vienna; Vienna Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University of Vienna; Vienna Austria
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University of Vienna; Vienna Austria
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Peltier AC, Donofrio PD. Chronic inflammatory demyelinating polyradiculoneuropathy: from bench to bedside. Semin Neurol 2012; 32:187-95. [PMID: 23117943 DOI: 10.1055/s-0032-1329194] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common treatable chronic autoimmune neuropathy. Multiple diagnostic criteria have been established, with the primary goal of identifying neurophysiologic hallmarks of acquired demyelination. Treatment modalities have expanded to include numerous immunomodulatory therapies, although the best evidence continues to be for corticosteroids, plasma exchange, and intravenous immunoglobulin (IVIg). This review describes the pathology, epidemiology, pathogenesis, diagnosis, and treatment of CIDP.
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Affiliation(s)
- Amanda C Peltier
- Department of Neurology, Vanderbilt Medical Center, Medical Center North, Nashville, Tennessee 37232-2551, USA.
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