Adverse outcomes and an immunosuppressed endotype in septic patients with reduced IFN-γ ELISpot

BACKGROUNDSepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients generally relies on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision.METHODSAn ex vivo whole-blood enzyme-linked immunosorbent spot (ELISpot) assay for cellular production of interferon γ (IFN-γ) was evaluated in 107 septic and 68 nonseptic patients from 5 academic health centers using blood samples collected on days 1, 4, and 7 following ICU admission.RESULTSCompared with 46 healthy participants, unstimulated and stimulated whole-blood IFN-γ expression was either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole-blood IFN-γ expression was significantly reduced on ICU days 1, 4, and 7 (all P < 0.05), due to both significant reductions in total number of IFN-γ-producing cells and amount of IFN-γ produced per cell (all P < 0.05). Importantly, IFN-γ total expression on days 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6, and procalcitonin. Septic patients with low IFN-γ expression were older and had lower ALCs and higher soluble PD-L1 and IL-10 concentrations, consistent with an immunosuppressed endotype.CONCLUSIONSA whole-blood IFN-γ ELISpot assay can both identify septic patients at increased risk of late mortality and identify immunosuppressed septic patients.TRIAL REGISTRYN/A.FUNDINGThis prospective, observational, multicenter clinical study was directly supported by National Institute of General Medical Sciences grant R01 GM-139046, including a supplement (R01 GM-139046-03S1) from 2022 to 2024.

Quercetin Alleviates Asthma-Induced Airway Inflammation and Remodeling through Downregulating Periostin via Blocking TGF-β1/Smad Pathway

INTRODUCTION

The aim of the study was to discuss whether the anti-asthmatic effect of quercetin is related to periostin and the downstream molecular pathway of quercetin's anti-asthmatic effect.

METHODS

We constructed asthmatic mice, sensitized by ovalbumin, and administrated different treatments into mice according to the experimental design. In this study, we mainly observed the inflammatory response, airway fibrosis, and airway hyperresponsiveness in asthmatic mice. Pathological stains (H&E, PAS, and Masson) were performed. We also detected the inflammation factors and fibrosis-related cytokines by enzyme-linked immunosorbent serologic assay. In addition, we also explored the level of periostin by enzyme-linked immunosorbent serologic assay and Western blot. At the same time, TGF-β1/Smad pathway was also determined by Western blot.

RESULTS

A high expression of periostin was found in asthmatic mice, and quercetin decreases periostin content in bronchoalveolar lavage fluid. Quercetin and OC-20 inhibit airway inflammation response, airway fibrosis, and airway hyperreactivity. Quercetin downregulated TGF-β1/Smad pathway in the lung tissues of asthmatic mice. Anti-asthma role of quercetin is related to periostin. Then deeper mechanical study revealed that inhibiting TGF-β1 could improve asthmatic symptoms, and quercetin exerted the protective effect on asthmatic mice through inhibition of TGF-β1/Smad pathway.

CONCLUSION

Quercetin provided a protective role against asthma via periostin, manifested by mild inflammatory infiltration, reduced goblet cell proliferation, and reduced airway fibrosis. TGF-β1/Smad pathway is an important transduction system, participating in the protective effect of quercetin on asthma.

Reflections on the role of carbon haemoadsorption in therapeutic medicine

The selection of Norit RBX-1-activated carbon granules for blood detoxification by haemoadsorption is outlined. Synthetic polymer membranes have been coated on to this carbon by a specially developed process and perfusion devices prepared from these materials have been evaluated in animal models of acute poisoning and liver failure. Clinical application of carbon haemoadsorption has been explored in acute poisoning, liver failure and uraemia. The experience to date would suggest that carbon will have to be augmented by other adsorbent species before life support systems based principally on haemoadsorption become a reality especially in the treatment of uraemia and in liver failure. A secondary role as a temporary adjunct to dialysis has been established for carbon haemoperfusion in the treatment of uraemic pericarditis and is under further investigation in the treatment of pruritus, pigmentation and neuropathy.

Hemoperfusion in 1981

The present status of hemoperfusion using the principle of artificial cells is described in detail using coated charcoal hemoperfusion as an example. The laboratory and clinical results show that in 1981 increasing numbers of new commercial models are approaching the efficiency and blood compatibility of the ACAC laboratory system. The results of hemoperfusion for uremia, acute intoxication and hepatic coma are analyzed. Other approaches are briefly discussed.

In vitro assessment of charcoal and resin hemoadsorbents

An in vitro assessment has been made of the blood compatibility and efficiency of different charcoal and resin hemoadsorbents. The charcoals vary in source, shape, size, nature and amount of polymer coating. The resins are the macroreticular adsorbents XAD-4 and Y56 and a carbonized resin. The effect on Y56 of albumin coating has been studied. The assessment has demonstrated that a reduction in platelet drop is accompanied by a decrease in the adsorption of fibrinogen. The results confirm the potential advantages of spherical charcoal and that coating with an ultrathin layer of polymer or with albumin does not seriously reduce efficiency. For Y56 resin, treatment with an albumin solution of 1-2 g/100 ml appears to be a suitable procedure if clinical use is considered.

Efficacy and safety of tandem hemodialysis and immunoadsorption to desensitize kidney transplant candidates

OBJECTIVES

We conducted a desensitization program in our center in patients undergoing kidney transplant for end-stage renal disease. These patients had a living-donor either ABO incompatible and/or human-leukocyte antigen-incompatible. The safety and efficacy of this program were evaluated.

MATERIALS AND METHODS

A pretransplant desensitization program relies on immunosuppressants and apheresis to remove detrimental antibodies. We chose immunoadsorption as the apheresis technique, and coupled this with hemodialysis in a tandem procedure.

RESULTS

We report on the efficacy of this new method in 120 procedures performed in 20 patients (14 ABO incompatible, 6 ABO incompatible/human leukocyte antigen-incompatible). The tandem procedure was well tolerated, and saved time compared with conducting sequential immunoadsorption and hemodialysis (6 h vs 10 h). The tandem procedure was associated with significantly decreased isoagglutinin titers and donor-specific alloantibodies (assessed by mean fluorescence intensity). Dialysance was effective (183, 102-264). The biochemical and hematologic parameters were similar to those observed after a conventional hemodialysis session, with the exception of protidemia; this might be related to some degree of albumin loss during the immunoadsoprtion procedure. The posttransplant events included 1) one ABO incompatible / human leukocyte antigenincompatible patient with vein thrombosis and ultimate kidney loss; 2) two patients with steroidsensitive cellular acute rejection; and 3) two patients with acute antibody-mediated rejection, which was successfully treated with apheresis and steroid pulses, plus rituximab in one and eculizumab in the other.

CONCLUSIONS

We conclude that the tandem immunoadsorption-hemodialysis procedure is efficient at desensitizing patients with end-stage renal disease who are candidates for a living ABO incompatible and/or human leukocyte antigenincompatible donor-kidney transplant.

Efficacy of immunoadsorption to reduce donor-specific alloantibodies in kidney-transplant candidates

OBJECTIVES

We implemented a desensitization program at our center to enable transplant in kidney-transplant candidates who have a living human-leukocyte antigen-incompatible (HLAi) donor. We report on the efficacy of semispecific immunoadsorption to allow HLAi kidney transplant in 6 highly sensitized patients.

MATERIALS AND METHODS

We chose immunoadsorption as the apheresis technique coupled to hemodialysis as a means to decrease donor-specific alloantibodies in kidney transplant candidates submitted to a pretransplant desensitization program to remove detrimental antibodies.

RESULTS

Six highly sensitized kidney-transplant patients (5 females), awaiting their first (n = 1) or second (n = 5) kidney transplant from a living donor, were enrolled in this desensitization program. They had 1 (n = 2), 2 (n = 1), 3 (n = 2), or 4 (n = 1) donor-specific alloantibodies; their mean fluorescent intensities at predesensitization ranged from 1200 to 19 000. Each patient underwent between 10 and 16 immunoadsorption sessions. At the time of transplant, donor-specific alloantibodies were undetectable in 2 patients (A24, DR3); donorspecific alloantibodies decreased by > 50% in 8 patients (A11, B44, DR3, DR11, DQ3 thrice, DQ5); donor-specific alloantibodies remained unchanged in 2 patients (B50, DR13); and mean fluorescent intensities were slightly increased in 2 patients (Cw6, DQ8). In the analysis of final outcomes, 2 patients experienced no rejection (1 experienced donor-specific alloantibody elimination, and 1 experienced a > 50% decrease in donor-specific alloantibodies). One patient presented with acute antibody-mediated rejection, which required immunoadsorption sessions and eculizumab therapy (donor-specific alloantibodies between 5000 and 19 000). Two patients presented with subacute antibody-mediated rejection; 1 was treated by plasmapheresis/rituximab therapy, and the other was treated with plasmapheresis/ methylprednisolone pulses. Another patient presented with chronic antibody-mediated rejection, which was treated unsuccessfully with plasmapheresis/rituximab; a tentative of rescue therapy with eculizumab was attempted without success.

CONCLUSIONS

Desensitization of the humanleukocyte antigen using this immunoadsorption procedure effectively reduced or eliminated donorspecific alloantibodies in 71% of patients undergoing kidney transplant, at the time of transplant.

Protein A immunoadsorption therapy in the highly sensitized kidney transplant candidates

BACKGROUND

Sensitization in transplant candidates increases risk of irreversible immunologic injury of graft in the early period postoperatively. Elimination of anti-human leukocyte antigen (HLA) antibodies using protein A immunoadsorption (IA) might benefit these patients.

METHODS

Protein A IA was used in 21 patients with high panel reactive antibody (PRA). The patients had IA 1 - 6 times (median 5 times) with the interval period was 2 - 5 days (median 2.5 days).

RESULTS

Total 67 IA procedures were carried out smoothly in all patients. IA treatment reduced PRA I (pre (31.4 ± 3.8)% vs. post (24.4 ± 3.4)%, P < 0.01) and II (pre (37.1 ± 4.3)% vs. post (34.1 ± 3.9)%, P < 0.01). However, PRA did not change in some patients after the treatment. The serum immunoglobulin (IgG, IgM and IgA) and complement C3, C4 level were decreased significantly. Hemoglobin and albumin levels were slightly decreased associated with IA procedures. Flu-like symptoms were observed in a few of cases during the procedure but generally mild and transient.

CONCLUSION

Protein A IA is capable to efficiently remove serum immunoglobulin and complement, reduce HLA class I and class II PRA in high sensitized transplant candidates, which is likely to benefit the kidney transplantation in these patients.

Extracorporeal Whole Blood Immunoadsorption of Autoimmune Myasthenia Gravis by Cellulose Tryptophan Adsorbent

Whole blood immunoadsorption (WBIA) system, using an adsorbent to remove pathogenic antibodies of myasthenia gravis (MG), was studied. Cellulose-tryptophan adsorbent was synthesized and its adsorption capacity of binding with acetylcholine receptor in the plasma of MG patient was evaluated. Experimental autoimmune myasthenia gravis (EAMG) rabbits were induced by Ta183-200 peptide. The rabbits underwent extracorporeal whole blood adsorption for 2 h. Results showed no significant damages on blood cells and no changes in the concentration of electrolytes. Total protein decreased by 12.0% (P < 0.05), and globulin protein decreased 23.9 +/- 5.6% (P < 0.05). The mean overall removal of antibodies against Ta183-200 was 41.12%. The percentage of decrement of compound muscle action potential in 3, 5, 10Hz of EAMG rabbits all dropped down after the treatment. In conclusion, the adsorbent is biocompatible, was safe for whole blood immunoadsorption, and can remove antibodies in an MG patient effectively. Whole blood immunoadsorption improved clinical manifestation and neuromuscular function of the EAMG rabbits.

Immunological mediated therapies for heart failure

Experimental and clinical data suggest a causal relationship between immunological and inflammatory processes and heart failure. Inflammatory processes may be involved in the pathogenesis of heart failure and may play a role in the progression of ventricular dysfunction. In the last decade several immunological methods were developed that tried to address these questions and overcome the inflammatory and immunological insults. We hope that the present review will increase awareness of new treatment options and encourage researchers and physicians to investigate this novel approach to treat patients with heart failure.

Advances in pemphigus therapy

The pemphigus variants represent a group of potentially life-threatening autoimmune mucocutaneous blistering diseases. Though systemic corticosteroids have dramatically reduced the rate of disease mortality, current therapeutic options are limited by their toxicity profiles. Advancements in our understanding of the molecular mechanisms involved in the pathogenesis of pemphigus have translated into the development of novel therapies. However, few treatments have been subject to randomized controlled trials to firmly establish therapeutic efficacy. Herein, we focus on the new and emerging therapies in the management of pemphigus.

Extracellular domains of the β, γ and ε subunits of the human acetylcholine receptor as immunoadsorbents for myasthenic autoantibodies: A combination of immunoadsorbents results in increased efficiency

Myasthenia gravis (MG) is usually caused by autoantibodies against the human muscle acetylcholine receptor (AChR). Plasmapheresis offers a therapeutic option, but, as well as removing the pathogenic anti-AChR autoantibodies, it non-specifically removes indispensable immunoglobulins. An attractive alternative to plasmapheresis would be the extracorporeal specific removal of the autoantibodies using AChR-based immunoadsorbents. Previously, we used the N-terminal extracellular domain (ECD) of the AChR alpha subunit to immunoadsorb anti-alpha subunit autoantibodies from MG sera. In this study, we immobilised the beta -, gamma- and epsilon-AChR ECDs on Sepharose and tested them as immunoadsorbents on 50 MG sera. A given ECD removed a different percentage of autoantibodies from different sera and different ECDs removed different percentages from the same serum; on average, the beta-, gamma- and epsilon-ECDs removed 22%, 20% and 15.5% of the autoantibodies, respectively. Immunoadsorption was completed in 3 min, 1 mug of ECD removed approximately 2 pmol of autoantibodies, and the immunoadsorbent could be recycled approximately 4 times. The combined use of two (alpha+gamma) or four (alpha+beta+gamma+epsilon) ECDs in a single immunoadsorbent resulted in much higher (often additive) immunoadsorption. These results show that MG sera have autoantibodies against several AChR subunits, and suggest that the combined use of all AChR ECDs could provide the basis for a novel, antigen-specific therapy for MG.

Specific immunoabsorption

Rapidly progressive glomerulonephritis occurs in patients developing autoantibodies to the glomerular basement membrane (GBM) and in multisystem vasculitic syndromes such as Wegener's granulomatosis (WG) and microscopic polyarteritis (MPA). In anti-GBM disease the pathogenicity of the autoantibodies has been established by transfer experiments; new solid-phase radioimmunoassays (RIAs) for circulating autoantibodies allow early diagnosis and effective monitoring of treatment. Sequential measurements of antibody levels showed that their generation is self-limiting (even without treatment) and that their production can be arrested more quickly with immunosuppressive therapy (cyclophosphamide and high dose steroids) together with intensive plasma exchange. In systemic vasculitis, no pathogenic agent has been identified and the diseases are rarely self-remitting. In WG, antibodies to cytoplasmic components of normal human neutrophils (and monocytes) were reported to be detectable by indirect immunofluorescence, with titres correlating with disease activity. We confirmed this and showed that antigen can be extracted from normal human neutrophils and used as ligand in a solid-phase RIA. Sera from patients with other forms of systemic vasculitis, such as MPA, as well as WG, are positive in this assay. The antigens have been further characterized by HPLC fractionation on a Toyosoda TSK gel filtration column. In WG, antibodies were directed towards cytoplasmic fractions of 100, 6 and 2 kDa; in MPA, antibody reacted only with the 100 kDa fraction. These findings suggest a humoral pathogenesis in these disorders and indicate that this approach may be helpful in the classification, diagnosis and monitoring of therapy in the systemic vasculitides. Further characterization of the autoantigen and its potential use in specific immunoabsorption are discussed.

In Vitro Evaluation of Biospecific and Pseudobiospecific Ligands Aimed at Extracorporeal Treatment for Immunoglobulin E Removal

This work investigated the potential use of an alternative adsorbent to anti-immunoglobulin E (IgE)-agarose for IgE selective adsorption therapy. A screening of several commercially available adsorbents (Concanavalin A, Lens culinaris[Lc], d-tryptophan, poly-l-lysine, and aminohexyl immobilized on agarose) was done through batch system assays, considering some criteria, such as adsorption capacity, selectivity, and biocompatibility. In the Lc-agarose adsorbent, total IgE, and specific IgE--for the airborne allergens Dermatophagoides pteronyssinus and Blomia tropicalis--were significantly better removed (63, 58, and 59%, respectively) than immunoglobulin G (19%), immunoglobulin A (33%), immunoglobulin M (9%), and albumin (18%). This adsorbent was packed into a column and the effect of superficial velocity, ratio of plasma volume to bed volume, number of perfusions, and temperature on IgE adsorption were evaluated. In vitro simulation of therapeutic adsorption (single perfusion) indicated that about 50% of total IgE could be eliminated.

Long-term Effects of a Multimodal Approach Including Immunoadsorption for the Treatment of Myasthenic Crisis

A multimodal treatment protocol with immunoadsorption (IA) as the central element was used in the treatment of myasthenic crisis (MC). Fifteen patients with MC were treated in repeated, uninterrupted 7-day cycles until mobilization with: (i) large-volume IA using an antihuman-IgG adsorber, days 1-5; (ii) intravenous immunoglobulin substitution (0.3-0.5 g/kg body weight [BW]/day), days 5-7; and (iii) immunosuppression with cyclophosphamide (1-2 mg/kg BW/day) and prednisolone (0.5-1 mg/kg BW/day), until remission. Patients required a median of 8 days of mechanical ventilation, 12 days in the intensive care unit, and 35 days of hospitalization. Functional improvement compared to their precrisis condition was attained by 14 of 15 patients. MG severity score improved by a mean of 10 points, quality of life score by 9.8 points, and Karnofsky index by 29 points in 14 of 15 patients. Improvements remained stable and no further crises occurred during long-term follow-up, which averaged 4.4 years. No fatalities due to MC occurred. The results demonstrate that our protocol is a potent therapeutic approach in the treatment of MC.

Das modifizierte Bonn-Malmö-Protokoll in der Behandlung der erworbenen Hemmkörperhämophilie

BACKGROUND AND OBJECTIVE

Autoantibodies directed against clotting factors can induce life threatening bleeding with a mortality rate up to 22%. Although the incidence of the disease is low (1-4 x 10(-6)), costs of treatment due to long-term clotting factor substitution can be enormous. Aim of an optimal treatment strategy should be to control bleedings by a rapid and safe elimination of the inhibitor and reinducing long-term immune tolerance.

PATIENTS AND METHODS

Treatment of 48 patients with acquired haemophilia A (m=20, f =28, age 61.3 (SD 16.4)), the largest patient collective world-wide, was monitored for a mean of 48 months. Three patients received only conservative treatment. 45 patients were treated intensively by a multimodal strategy including: 1. immunoadsorption for antibody elimination; 2. FVIII substitution; 3. intravenous immunoglobulin substitution and 4. immunosuppression. The times required for inhibitor elimination, factor VIII substitution and the duration of the MBMP were documented.

RESULTS

In 45 patients with a high titre critical bleeding was controlled immediately after the initiation of MBMP. There were no deaths from bleeding or the treatment. Inhibitor levels decreased to undetectable levels within a median of 3 days (95% CI, 3-7 days), factor substitution was terminated within a median of 13 days (95% CI, 10-16 days) and the treatment was completed within a median of 15 days (95% CI, 13-17 days). The overall response rate for complete remission (CR) was 91%. When cancer patients were excluded, the CR rate was 97%.

CONCLUSION

Considering the short duration and amount of factor VIII substitution, the short time of hospitalization and the long-term median follow up of 48 months without bleeding events, the MBMP appears to have a modifying effect on the immunological response.

Anti-inflammatory trials in chronic heart failure

Chronic heart failure (CHF) is accompanied by a dysregulated cytokine network, which is characterized by a rise in inflammatory cytokines and an inadequate elevation of anti-inflammatory mediators. This dysregulation has been implicated in the development and progression of CHF and, in the last decade, attempts have been made to modulate this imbalance in the cytokine network. With the exception of one larger mortality/morbidity study, all studies of immunomodulatory therapy in HF conducted to date have included <100 patients and the overall experience in this therapeutic area is limited compared with studies of neurohormonal antagonists, which have included several thousand patients. While trials of anti-tumor necrosis factor therapies have thus far failed, recent studies of broad-based immunomodulatory agents (e.g. intravenous immunoglobulin, thalidomide, and pentoxifylline) highlight a potential for such therapy in HF patients, in parallel with optimal cardiovascular treatment regimens. In addition to identifying the crucial factors in the immunopathogenesis of CHF in order to develop novel immunomodulatory treatment strategies, there is a clear need to confirm the results of the smaller studies conducted to date with larger placebo-controlled mortality studies that involve a diverse group of patients, with regard to the cause and severity of HF.

Increased Ethyl Mercury Load in Protein A Immunoadsorption

Immunoadsorption is an adsorption technique for extracorporeal removal of circulating autoantibodies in autoimmune diseases. To prevent microbial growth during storage, the protein A columns are primed with thiomersal, which contains toxic ethyl mercury, which may be released during the procedure and potentially begin to accumulate and become toxic. To reduce the thiomersal-related mercury release during immunoadsorption treatment, we introduced a modified rinsing solution containing N-acetylcysteine, which is an avid mercury scavenger. Thirteen patients received 17 protein A immunoadsorption treatments and their venous blood samples were collected immediately before and after each session. The total blood mercury levels were measured by atomic absorption spectrometry, and the ethyl mercury levels by atomic fluorescence spectrometry. Following the manufacturer's recommendations, we used 600 mg of N-acetylcysteine to rinse the mercury from protein-loaded columns before each immunoadsorption treatment. After immunoadsorption, the ethyl mercury levels increased from 0.148 +/- 0.402 ng/g to 2.026 +/- 1.944 ng/g (P < 0.001), and the total blood mercury levels increased from 2.447 +/- 3.065 ng/g to 20.437 +/- 28.603 ng/g (P = 0.02). The post-treatment values of total blood mercury exceeded the upper safety level of 5 ng/g in all 17 immunoadsorption treatments, but no patient developed clinical signs of mercury toxicity. The results of our study showed an increase in total blood mercury and ethyl mercury levels during the immunoadsorption treatments, suggesting mercury release from thiomersal-primed columns despite the addition of N-acetylcysteine to the rinsing solution.

In vitro assessment of a new ABO immunosorbent with synthetic carbohydrates attached to sepharose

Transplantation across the ABO barrier is sometimes done in cases of emergency, such as acute liver failure, but is also carried out in elective cases, e.g. kidneys from living donors. Reducing the recipient anti-A/B antibody titres is often necessary in ABO-incompatible kidney transplantation. This is usually done by the use of techniques such as plasmapheresis and protein A- or sepharose-linked anti-human Ig immunoadsorption. A new ABO immunosorbent with synthetic A- or B-trisaccharide carbohydrate epitopes linked to a sepharose matrix has been tested. Columns made of this material have been tested in vitro with plasma from A- and B-individuals, assessed for antibody reduction capacity, flow characteristics, biocompatibility, and unspecific protein adsorption. The columns have a high capacity for ABO antibody removal, reducing titres by three to seven steps in one passage. We noted a high biocompatibility, with no unspecific protein adsorption, no activation of coagulation factors, and a low activation of complement, no immune complex formation and no cytotoxicity towards cultured mammalian L929 cells.

Successful removal of pathogenic autoantibodies in pemphigus by immunoadsorption with a tryptophan-linked polyvinylalcohol adsorber

BACKGROUND

Autoantibodies against the glycoproteins desmogleins 1 and 3 which are components of the desmosomal adhesion complex have been shown to be responsible for the loss of epidermal adhesion characteristic of pemphigus. Elimination of these antibodies should clinically improve the pathology of this group of severe autoimmune blistering skin disorders.

OBJECTIVES

To gather information about the efficacy of immunoadsorption in the reduction of pathogenic serum autoantibodies against desmogleins 1 and 3 and to evaluate the clinical benefit of immunoadsorption in the treatment of pemphigus.

PATIENTS AND METHODS

Nine patients with pemphigus and detectable circulating desmoglein antibodies were included in this open trial. Two immunoadsorption treatments separated by a 48-h interval were performed per patient. Anti-desmoglein 1 and 3 antibodies in the patients' sera were monitored by enzyme-linked immunosorbent assay and indirect immunofluorescence before and following each immunoadsorption. In addition, the efficacy of the tryptophan-linked polyvinylalcohol adsorber in removing antidesmoglein antibodies was directly evaluated.

RESULTS

IgG antibodies against desmogleins 1 and 3 were effectively eliminated from the patients' plasma upon passage through the adsorber and levels of serum autoantibodies were significantly reduced by immunoadsorption. A single immunoadsorption treatment led to a reduction of antidesmoglein autoantibodies of about 30%. Clinically, mucosal and cutaneous lesions improved allowing for a reduction of the systemic immunosuppressive treatment with glucocorticoids.

CONCLUSIONS

Immunoadsorption with tryptophan-linked polyvinylalcohol adsorbers holds promise as a highly effective and safe adjuvant therapeutic regimen in pemphigus.

Immunoadsorption apheresis (Selesorb) in the treatment of chronic hepatitis C virus-related type 2 mixed cryoglobulinemia

In this short-term open label clinical pilot study, conducted at one center, the immune complex dextran sulphate adsorber (Selesorb) was used to treat four female patients aged 59-69 with HCV-related cryoglobulinaemia, vasculitis and/or neuropathy. The primary trial objective was to assess the clinical efficacy of the immunoadsorber. The secondary objective of the trial was to determine the safety of the adsorber and to investigate the adsorption capacity, measured as the adsorption of cryoglobulin-related immune complexes and the resulting influence on plasma components of the immune system. The patients have been submitted to treatment with the immunoadsorber, at approximately 1-3 days intervals, completing six sessions. The follow-up was one month. In the patients treated with Selesorb, we observed a statistically significant decrease in plasma of all classes of immunoglobulins (IgA: 5-28%; IgG: 14-44%; IgM: 8-38%). In two patients with peripheral neuropathy secondary to cryoglobulinemia, the symptomatology was improved. In a third patient the neurological involvement was substantially unchanged, and the same unsuccessful outcome was observed for Sjögren syndrome is concerned. Nevertheless, the two patients with lower extremity vasculitis showed an appreciable improvement. We failed to observe significant side effects directly related to the use of this immunoadsorbent.

Emerging technologies in extracorporeal treatment: focus on adsorption

As an extracorporeal technique for blood purification, haemoadsorption was introduced in the early 1960s along with other physico-chemical methods. The problem of poor biocompatibility of uncoated adsorbents was resolved by coating adsorbent granules with haemocompatible membranes. Use of coated adsorbents instead of uncoated ones reduces the efficiency of haemoperfusion. As a result, for many years the use of adsorption was limited to only acute poisoning. Since the 1990s interest in the use of adsorbents in extracorporeal medical devices has been rising again. In this paper some recent developments in synthesis and application of novel uncoated medical adsorbents are discussed.

Peptide based adsorbers for therapeutic immunoadsorption

Peptides as ligands for immunoadsorption exhibit several potential advantages over native proteins. Two newly developed adsorbers are based on peptides covalently coupled to sepharose CL-4B. Globaffin is capable of binding immunoglobulins independent from their antigen specificity and thus, applicable in transplant recipients and several antibody mediated autoimmune diseases. Among others, the most important disorders suitable for the treatment with Globaffin are rheumatoid arthritis, systemic lupus erythematosus, and acute renal transplant rejection. Coraffin is a specific adsorber using two linear peptide ligands mimicking epitopes of the beta1-adrenergic receptor, that bind corresponding autoantibodies from patients suffering from idiopathic dilated cardiomyopathy. Specific immunoadsorption has been shown to be beneficial for patients with dilated cardiomyopathy. Coraffin can be used as a new therapeutic option for these patients, who get only limited benefit from medical therapy. Both adsorbers may be combined with all approved apheresis control devices available.

Immusorba TR and PH

Immusorba TR (IM-TR) and PH (IM-PH) were developed as adsorbents with non-biological materials as affinity ligands to remove pathogenic autoantibodies. The adsorbents of IM-TR and IM-PH are polyvinyl alcohol gel immobilized with tryptophan and phenylalanine as ligand, respectively. IM-TR is clinically applied for treatment of autoimmune neurological diseases such as myasthenia gravis and Guillain-Barre syndrome. IM-PH is used for not only neurological diseases such as GBS and multiple sclerosis but also collagen diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). As many autoantibodies with different specificities have been found to have similar affinities to the ligand of Immusorba, it is expected that Immusorba will be applied to more diseases and contribute to the clarification of the mechanisms of the development of diseases by the identification of adsorbed unknown pathogenic substances with Immusorba.

[Outcome of pregnancy with systemic lupus erythematosus treated with DNA immunoabsorbent]

OBJECTIVE

To study the outcome of pregnancy with systemic lupus erythematosus (SLE) treated by DNA immunoabsorbent therapy.

METHODS

Sixty nine SLE women with pregnancy were randomly enrolled into DNA immunoabsorbent group (35, group I) and common therapeutic group (34, group II) as control. Outcomes of pregnancy and complications were analyzed.

RESULTS

The incidence of complication and fetus loss in group I was 28.6% (10 cases) and 20.0% (7 cases), while 85.3% (29 cases) and 58.8% (20 cases) in group II, there was very significant difference respectively (P < 0.01). The incidence of premature birth was 8.6% (3 cases) in group I, 26.5% (9 cases) in group II, the difference was significant (P < 0.05).

CONCLUSION

DNA immunoabsorbent was more efficient than common therapy in the management of SLE with pregnancy.

Immunoadsorption, current status and future developments

The association of abnormalities in the cellular and humoral immune system with various autoimmune diseases provides the rationale for apheresis technologies. While plasmapheresis or plasma exchange is limited by its non-selective removal of all plasma components, modern apheresis techniques aim to provide more specific elimination according to clinical needs and avoid plasma product replacement. However, the commercialisation has not met the expectations in the early 80's and the number of patients treated by extracorporeal immunoadsorption remains small due to a lack of well-defined controlled trials and limited reimbursement. This review highlights the immunological and technical basis for extracorporeal immunoadsorption, as well as its current status in the treatment of immunologically-mediated diseases.

A novel immunoadsorbent for rheumatoid arthritis therapy--preparation and efficacy evaluation

AIM

To develop a novel immunoadsorbent for rheumatoid arthritis (RA) therapy.

METHODS

A RA immunoadsorbent was developed by binding heat-aggregated human IgG(HAHIgG) to porous agar gel beads. Its adsorption capacity for rheumatoid factors (RFs), storage stability and blood compatibility were evaluated.

RESULTS

The coupling yield of HAHIgG on the carrier was 6.0 mg/g wet gel. Saturation adsorption capacity of the adsorbent for IgMRF, IgGRF and IgARF were 3400, 2240 and 2400 IU/g, respectively. The adsorbent can be stored at 4 degrees C for three months without significant variance in its activity. Its fine permeability and hemocompatibility were demonstrated by extracorporeal hemoperfusion on rabbits.

CONCLUSION

HAHIgG/agar gel is a safe and effective immunoadsorbent for RA therapy, its potential clinical use is promising in the future.

Double filtration plasma exchange and immunoadsorption therapy in a case of stiff-man syndrome with negative anti-GAD antibody

We report the effects of double filtration plasma exchange and immunoadsorption therapy which were performed for a case of stiff-man syndrome even though the patient was negative for anti-glutamic acid decarboxylase (GAD) antibody. The patient underwent a course of four double filtration plasma exchanges, which resulted in marked clinical improvement. Painful muscle cramps disappeared and muscle stiffness reduced within a day after the first plasma exchange. The patient's improvement continued, but his condition declined again about ten months after plasma exchange. Immunoadsorption therapy was then performed, and this treatment was also effective.

Removal of immunoglobulins by a protein A versus an antihuman immunoglobulin G-based system: evaluation of 602 sessions of extracorporeal immunoadsorption

Elimination of IgG can be achieved by extracorporeal immunoadsorption (IA) based on specific binding to either staphylococcal protein A (Excorim) or sheep polyclonal antibodies directed against human IgG (Therasorb). In 602 analyzed sessions of IA, elimination of IgG was 60% through 80% depending on the treated plasma volume, with no significant difference between the mentioned systems. However, the decrease of IgM and IgA was approximately 50% in the anti-IgG compared to 20-40% in the protein A system. Plasma albumin concentration decreased by 20% in the anti-IgG system compared to 15% in the protein A system, and hemoglobin values increased by 2% in the anti-IgG system and decreased by 6% in the protein A system. In conclusion, a clinical relevance for these findings cannot be ruled out, and the individual choice might depend on the clinical situation and laboratory findings.

[Experimental study on hemoperfusion to remove CIC in blood of rabbit with an affinity adsorbent II]

In this study a rabbitmodel of high concentration cycle immune complex (CIC) was established, and then an experimental hemoperfusion using AA3 Adsor-bent was performed the effect of hemoperfusion to remove CIC in blood and the influence of AA3 on hemocompatibility and proteins were observed.

Low-density lipoprotein (LDL) oxidizability before and after LDL apheresis

Oxidation of low-density lipoprotein (LDL) plays a major role in the development of atherosclerosis. Hypercholesterolemia has been associated with enhanced in vitro oxidation of LDL, and lipid-lowering therapy reduces LDL oxidizability. In the present study, we investigated whether LDL apheresis performed with different techniques affects in vitro diene formation (lag phase) and modification of apolipoprotein B-100 (apoB). Baseline and posttreatment diene formation was correlated with the baseline pattern of plasma total fatty acids. We then performed a computer-simulation study to test the hypothesis that LDL apheresis-induced changes in LDL oxidizability are related to changes in the mass ratio between freshly produced and older LDL. In 19 patients aged 49+/-7 years with heterozygous familial hypercholesterolemia (FH) regularly treated with either immunoadsorption, heparin-induced LDL precipitation (HELP), or dextran sulfate (DS) adsorption, we determined lipoprotein levels, the lag phase, apoB modification, and the fatty acid pattern in plasma samples drawn at the onset and termination of one LDL apheresis. LDL apheresis significantly decreased total cholesterol, high-density lipoprotein (HDL) cholesterol, LDL cholesterol, and triglycerides by 50.4%, 14.9%, 62.6%, and 33.6%, respectively. The lag phase increased by a significant mean of 9.8%; the charge of apoB was not altered. The lag phase before treatment positively correlated with the baseline concentration of plasma total palmitic, myristic, and oleic acid. The increase in the lag phase during treatment correlated with a high pretreatment concentration of lauric, linoleic, and docosahexanoic acid. The simulation study indicates that a temporary imbalance between two LDL compartments, one representing freshly secreted LDL and the other representing older LDL, could explain the observed increase in the lag phase after LDL apheresis. In conclusion, in patients with heterozygous FH, LDL apheresis performed with different techniques decreases the susceptibility of LDL to oxidation. This decrease may be related to a temporary mass imbalance between freshly produced and older LDL particles. Furthermore, the baseline fatty acid pattern influences pretreatment and posttreatment susceptibility to oxidation.

Preparation of DNA-immobilized immunoadsorbent for treatment of systemic lupus erythematosus

A new DNA-immobilized immunoadsorbent was prepared to remove the pathogenic anti-DNA antibody from the serum of systemic lupus erythematosus (SLE) patients. A non-woven poly(ethylene terephthalate) (PET) fabric made of 3.5-microm diameter fibers was used as the support of the immunoadsorbent. A cationic monomer, N,N-dimethylaminoethyl methacrylate (DAM), was graft polymerized onto the PET fiber surface by UV irradiation or with a chemical initiator. Polyion complexation between the cationic groups of the graft chains and DNA molecules was employed to immobilize DNA onto the fiber surface. No DNA leaching was observed when the DNA-immobilized fabrics were placed in 0.9 and 2.0 wt% NaCl solution at 37 degrees C overnight. In vitro evaluation of this DNA-immobilized immunoadsorbent demonstrated that this adsorbent could selectively adsorb anti-DNA antibody from the serum of SLE patients.

Immusorba TR and Immusorba PH: basics of design and features of functions

Immusorba was reported by Yamazaki et al. to be the world's first practical immunoadsorbent in 1982. Since then, this immunoadsorbent has accumulated an abundance of clinical achievements. Immusorba has such unique functions that it is used in treating various diseases and holds possibilities for application to more diseases. Immusorba was designed as an artificial receptor for rheumatoid factor (RF) based on structural analysis of heat-denaturated globulin. Subsequently, new substances that it can adsorb have been found as seen in reports on the adsorption performance of Immusorba to anti-acetylcholine receptor antibodies (anti-AChR Abs) and antiganglioside antibodies. Along with this, Immusorba has been used in treating a wide range of diseases. The greatest characteristic of Immusorba is that its adsorption capability is selective rather than specific, making it effective against a great number of diseases.

Clinical trials of type I and in vitro studies of type II immunoadsorbents for systemic lupus erythematosus therapy

A highly selective immunoadsorbent was prepared by immobilization of DNA on carbonized resin beads (Type I) for the removal of the pathogenic antibodies of systemic lupus erythematosus (SLE) patients. Thirty cases of clinical trials of this SLE therapy were performed at 12 hospitals in China. The levels of anti-DNA antibodies after whole blood perfusion were decreased 40-70%. Almost all the symptoms were relieved, and some patients were freed from medicine administration. A new immunoadsorbent was prepared using aminated cellulose beads (Type II) having a higher DNA immobilization capacity of 0.6 mg/ml than the 0.4 mg/ml capacity for Type I. Stationary adsorption tests with the sera of SLE patients showed that the Type II immunoadsorbent could remove 60% of the pathogenic antibodies, which is much higher than the 30% for the Type I adsorbent.

Lipoprotein (a) immunapheresis in the treatment of familial lipoprotein (a) hyperlipoproteinemia in a patient with coronary heart disease

This paper reports 2 years' experience with lipoprotein (a) (Lp[a]) immunapheresis which was successfully handled on a now 40-year-old patient with familial Lp(a) hyperlipoproteinemia inducing severe coronary heart disease with 2 myocardial infarctions and diffuse coronary sclerosis. Continued treatment by Lp(a) immunabsorption with specific sheep antibodies reduced stenosis in coronary vessels more than 50% and stopped the progression of coronary heart disease. A special apheresis technique and the results of continued absorption effects are described.

Specific immunoadsorbent for myasthenia gravis treatment: development of synthetic peptide designed to remove antiacetylcholine receptor antibody

We have developed Medisorba MG, a new immunoadsorbent column for myasthenia gravis (MG). The alpha 183-200 segment of the Torpedo Californica acetylcholine receptor (AChR) is recognized as the acetylcholine binding site by the blocking antibody, which is one of the anti-AChR antibodies involved in the pathogenesis of MG. As a specific affinity ligand to remove the blocking antibody, Torpedo alpha 183-200 was synthesized and immobilized covalently to porous cellulose beads. This immunoadsorbent showed specific removal of the blocking antibody without reducing IgG and albumin levels significantly in clinical evaluation and in vitro study. Clinical improvement was found in 78% of the cases, and no adverse effects were observed in any case. The Medisorba MG column has been confirmed as a useful device for the treatment of MG.

Course of islet autoantibody titers during Ig-immunoadsorption in a patient with newly diagnosed type 1 diabetes

The purpose of this study was to determine whether and to what extent diabetes-specific autoantibodies can be removed from the plasma by Ig-immunoadsorption therapy. We followed the course of islet cell antibodies (ICA), insulin antibodies (I[A]A), glutamic acid decarboxylase antibodies (GADA) and antibodies to the protein tyrosine phosphatase IA-2 (IA2A) in a patient with newly diagnosed insulin-dependent diabetes mellitus (IDDM) under multiple immunoadsorption treatments over 6 months. Autoantibodies were not removed from the plasma as efficiently as expected when compared to the removal of total immunoglobulin (IgG). Whereas IgG levels were lowered by 70-90% through each immunoadsorption treatment, antibodies to insulin were reduced by an average of 83%, IA2A by 36% and GADA by only 9% directly after treatment. ICA were > 320 JDF U at diabetes onset and remained above this level. During the 6 months of multiple immunoadsorption therapies, I[A]A levels showed a 24-fold increase due to stimulation of insulin antibody production by exogenous insulin substitution, IA2A levels remained unchanged (average 6% increase), and GADA levels were reduced by an average of 39% compared to antibody titers at onset. All four antibodies were highly positive in the eluate from the immunoadsorption columns. We showed that antibodies to pancreatic islet cells can be reduced by immunoadsorption, but as for plasmapheresis the effect is incomplete and transient for most of the antibodies. If there is clinical benefit through immunoadsorption therapy--as has been shown for newly diagnosed IDDM patients treated with plasmapheresis--our data suggest that this may be due to factors other than the sufficient removal of antibodies.

[Efficacy of immunosorption in patients with systemic lupus erythematosus: double blind controlled trial]

Efficacy of immunosorption (IS) employing perfusion of whole blood through activated charcoal containing DNA was studied in 11 patients with systemic lupus erythematosus (SLE). 11 SLE patients exposed to hemosorption on charcoal free from DNA served as controls. When used in combination with intensive therapy (corticosteroids and cytostatic immunosuppressant), IS produced a positive effect on lupus nephritis symptoms in 8 out of 10 patients with kidney affection. AntiDNA antibodies blood level decreased by 53.6% after two IS procedures, while only by 36.4% after nonselective hemosorption. Reduced count and functional activity of B-cells recorded after IS contribute much to final outcome of the treatment.

Immunoadsorption plasmapheresis in acute ataxic neuropathy

Acute ataxic neuropathy is characterized by sensory ataxia and areflexia. There is no established treatment. We tried immunoadsorption plasmapheresis 15 days after the onset for a 46-year-old woman suffering from this neuropathy. She could not walk even with assistance because of sensory ataxia. A sural nerve biopsy revealed active axonal degeneration and loss of myelinated fibers. We tried 5 sessions of plasmapheresis during 2 weeks. She could walk with assistance 12 days after the beginning of the plasmapheresis treatment. It took 3 months for her to be able to walk over 5 m without assistance, and she had severe sensory ataxia over a 17 month follow-up period. Immunoadsorption plasmapheresis started within 2 weeks after the onset of acute ataxic neuropathy may have beneficial effects if the axonal degeneration is mild. The plasmapheresis, however, should be continued for a longer period. A double blind study is necessary to clarify the effectiveness of this treatment on acute ataxic neuropathy.

In vivo immunoadsorption of antipig antibodies in baboons using a specific Gal(alpha)1-3Gal column

The major role of anti-alphaGal antibodies in the hyperacute rejection of pig organs by humans and baboons has been clearly demonstrated. Spacered alpha-galactose disaccharide (Gal(alpha1)-3Gal) hapten was produced by chemical synthesis and covalently attached to a flexible, hydrophilic polymer (PAA), which in turn was covalently coupled to macroporous glass beads, forming an immunoadsorbent that is mechanically and chemically stable and can be sterilized. The extracorporeal immunoadsorption (EIA) of anti-alphaGal antibodies using this column has been investigated in vivo in 3 baboons. In Baboon 1 (which had hyperacutely rejected a pig heart transplant 4 months previously, was not splenectomized, and did not receive any pharmacologic immunosuppression) the levels of anti-alphaGal antibody and antipig IgM and IgG, as well as serum cytotoxicity, fell significantly after each of 3 EIAs but were not eliminated. Serum cytotoxicity, antipig immunoglobulin and anti-alphaGal antibody rose steeply within 24 hr of the final EIA, suggesting that the return of cytotoxicity was associated with anti-alphaGa1 antibody. In Baboons 2 and 3 (which were immunologically naive and splenectomized, and received triple drug immunosuppressive therapy) serum cytotoxicity was totally eliminated and anti-alphaGal antibody and antipig IgM and IgG levels were greatly reduced by courses of EIA. In Baboon 2, cytotoxicity and all antibody levels remained negligible for approximately one week after the final (fourth) daily EIA. In Baboon 3, cytotoxicity and antibody levels were maintained low by intermittent EIA (over a period of 13 days) for almost 3 weeks, although antipig IgM began to rebound 4 days after the final EIA. We conclude that, in an immunosuppressed, splenectomized baboon, repeated EIA using a specific alphaGal disaccharide column will reduce antipig and anti-alphaGal antibody levels and serum cytotoxicity significantly for several days. This reduction in cytotoxicity will almost certainly be sufficient to delay the hyperacute rejection of a transplanted pig organ, but further studies are required to investigate whether it will be sufficient to allow accommodation to develop.

Reduction of plasma fibrinogen, immunoglobulin G, and immunoglobulin M concentrations by immunoadsorption therapy with tryptophan and phenylalanine adsorbents

Immunoadsorption (IA) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session I plasma volume (2.8 +/- 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonparametric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.

Lymphocytapheresis

Leukocytapheresis has long been performed with the centrifugal method. But in 1989 in Japan, the Asahi Medical Co. developed the extracorporeal leukocyte-removal filter, Cellsorba. This filter consists of non-woven fabric, which can remove leukocytes from whole blood during extracorporeal circulation. In the incipient stage, this filter was applied to collagen diseases, rheumatoid arthritis, and systemic lupus erythematosus. During the following studies, this filter has been found to have an immunosuppressive effect. Now, it is beginning to be applied to various kinds of autoimmune diseases. Moreover, this filter has recently been recognized to be effective in inflammatory bowel diseases, ulcerative colitis, and Crohn's disease. The outline of Cellsorba and the application of this filter is described here.

Current status in extracorporeal immunomodulation: immune disorders

Today, clinicians can choose from a variety of extracorporeal immunomodulatory procedures such as plasma exchange, double filtration, immunoadsorption, chemoadsorption, photopheresis, and cytoapheresis. The mechanisms underlying extracorporeal immunomodulation (ECIM) comprise removal of pathogenic antibodies and circulating immune complexes as well as reticuloendothelial system deblockage; modification of immune complex structure and processing can be induced by changing the antigen/antibody ratio and by modulation of immune complex solubility via complement activation. Finally, cellular components like lymphocyte subsets, can be modified. Clinical examples of ECIM include lupus erythematosus, Goodpasture's syndrome, anti-neutrophil cytoplasmatic antibodies-mediated systemic vasculitis, myasthenia gravis, and, hypothetically, sepsis.

Immune modulation associated with extracorporeal immunoadsorption treatments utilizing protein A/silica columns

The Prosorba column is designed for the removal of IgG and IgG containing immune complexes from plasma. Clinical studies employing patients presenting with idiopathic thrombocytopenic purpura (ITP) indicate that this new form of therapy is effective in approximately 40% of treated patients. Responding patients exhibit a significant increase in platelet numbers associated with decreases in antiplatelet antibody and immune complexes suggesting the induction of immune modulation. Preliminary studies indicate that ITP patients presenting with antiplatelet IgG antibody are those most likely to respond. In addition, this subgroup of ITP patients also exhibit elevated levels of antiidiotypic IgG antibody, which may contribute to an exacerbation of the autoimmune process due to antigen mimicry of the platelet autoantigen. Interestingly, antiidiotypic IgG antibody levels appear to decrease in association with antiplatelet IgG autoantibody levels suggesting that removal of immune complexes composed of IgG autoantibody and platelet autoantigen and/or antiidiotypic IgG antibody may be related to the observed clinical responses. Additional studies with alloimmune patients refractory to platelet transfusion suggest that transfused platelet retention time may be increased as a consequence of immunoadsorption therapy. This clinical response appears to be related to decreases in IgG alloantibody, again suggesting the induction of immune modulation. Alloimmune thrombocytopenic patients also appear to present with elevated levels of antiidiotypic IgG antibody which may contribute to an exacerbation of the alloimmune process due to antigen mimicry of platelet alloantigen(s). Preliminary studies indicate that both IgG alloantibody and corresponding antiidiotypic IgG antibody levels appear to decrease during immunoadsorption therapy, which suggests that removal of these antibodies, possibly in the form of immune complexes, may be related to clinical responses. Finally, studies in rheumatoid arthritis patients suggest that immunoadsorption therapy may be of clinical benefit in this autoimmune disorder. Consistent with the results observed above, preliminary studies in patients responding to immunoadsorption treatments again suggest that there is a concomitant decrease in idiotypic IgG (rheumatoid factor) and antiidiotypic IgG antibodies levels during therapy.

5-year follow-up of patients successfully transplanted after immunoadsorption to remove anti-HLA antibodies

The function of renal allografts in patients who had received pretransplant immunoadsorption in order to remove cytotoxic anti-HLA antibodies was studied. We reviewed 6 patients who received a graft which functioned beyond 3 months; the mean follow-up period was 76 (range 62-89) months. Two grafts have been lost from chronic rejection, at 12 and 62 months, respectively. The mean plasma creatinine levels at 1 and 5 years were 169 (range 143-211) mumol/l and 155 (range 92-235) mumol/l, respectively (1.91, range 1.62-2.39, mg/dl and 1.75, range 1.04-2.66 mg/dl, respectively). The major source of morbidity during long-term follow-up has been the occurrence of renal artery stenosis in 5 patient and renal vein stenosis in 1. In conclusion, the 5-year graft survival and function was good in patients who received immunoadsorption and whose grafts survived beyond the first 3 months after transplantation.