Plasma-exchange in the treatment of cryoglobulinemia

Summary Plasma-exchange was used in 10 patients with mixed cryoglobulinemia. The procedure was used as a primary therapeutic tool to reduce cryoglobulin levels, and in combination with prednisone and cytotoxic drugs. The results show that PE alone is detrimental, although it may be an important adjunct to conventional therapy in MCG with progressive deterioration in the clinical condition, and in those patients who do not respond to drug therapy alone. The weak response to PE in MCG may be due to many technical variables, but mainly to the low percentage of circulating cryoglobulins removed. This study was supported in part by grant no. 82/7206-82/7207 of theMinistero della Pubblica Istruzione, Italy.     

Prevention of cryoprecipitation during cardiopulmonary bypass in a patient with HIV-HCV co-infections

BACKGROUND: There are no guidelines for the management of patients with cryoglobulins during cardiopulmonary bypass (CPB) necessitating core hypothermia. OBJECTIVE: To evaluate a simple, pragmatic protocol of in vitro temperature-dependent cryoprecipitation of serum in patients with cryoglobulinemia before elective cardiac surgery with CPB. METHODS: A 44-year-old female patient was known for chronic hepatitis C and type III cryoglobulinemia. Elective surgery was planned for an aortic arch aneurysm. A differential serum cryoprecipitation profile was established in vitro prior to surgery. RESULTS: Whereas, at temperatures < or = 15 degrees C, cryoglobulin levels were > or = 0.112 g/L (normal value < 0.05 g/L), at 20 degrees C and above, the precipitate was < or = 0.016 g/L. Accordingly, surgery was performed without any cryoglobulin-related complications at an extracorporeal circulation temperature of 22-24 degrees C, to minimise the risk of cryoprecipitation. CONCLUSION: In elective cases of surgery with CPB and hypothermia, temperature-dependent differential serum cryoprecipitation profile may be an easy and efficient way to assess a safe peroperative level of temperature to avoid complications due to cryoglobulins, without enhancing the patient's tissue ischemia risks.     

Hepatitis C virus positive patient diagnosed after detection of atypical cryoglobulin

A 60-year-old male patient presented with jaundice and dark urine for three days, icteric sclerae and skin rash on his legs for six months. Laboratory investigations revealed an atypical cryoglobulinemia with high hepatitis C virus (HCV)-RNA levels. Imaging studies showed cholestasis was accompanying HCV. Capillary zone electrophoresis using immunosubtraction method revealed a polyclonal immunoglobulin G and immunoglobulin A (IgA) monoclonal cryoglobulin and that IgA lambda was absent in immunofixation electrophoresis. After a liver biopsy, chronic hepatitis C, HCV related mixed cryoglobulinemia and cryoglobulinemic vasculitis were diagnosed and antiviral therapy was initiated. Our HCV patient presented with cryoglobulinemic symptoms with an atypical cryoglobulinemia that was detected by an alternative method: Immunosubtraction by capillary electrophoresis. Different types of cryoglobulins may therefore have a correlation with clinical symptoms and prognosis. Therefore, the accurate immunotyping of cryoglobulins with alternative methods may provide more information about cryoglobulin-generated pathology.     

Hepatitis C virus infection and mixed cryoglobulinemia: a striking association

Summary The high frequency of liver involvement in cryoglobulinemia is well established. Although both etiology and pathogenesis have remained so far undefined, recent studies suggest an association of mixed cryoglobulinemia with hepatitis C virus infection. To explore this hypothesis further, we assessed the prevalence of hepatitis C virus antibodies and RNA in a large group of patients, including: (1) 35 patients with cryoglobulinemia without clinical evidence of liver involvement (group 1), (2) 15 patients with symptomatic cryoglobulinemia associated with chronic liver disease (group 2) and (3) 13 patients with asymptomatic cryoglobulinemia associated with chronic liver disease (group 3). Anti-hepatitis C virus antibodies were detected by a second-generation enzyme-linked immunosorbent assay and third-generation immunoblot (SIA Prototype RIBA), whereas the polymerase chain reaction was used for the detection of viral RNA Anti-hepatitis C virus antibodies, as detected by enzyme-linked immunosorbent assay, were demonstrated in 21 (60%) patients from group 1, 11 (73,3%) from group 2 and 10 (83.3%) from group 3. The immunoblot identified as positive 3 further patients in group 1 (giving a prevalence of 68.6%) and all patients in groups 2 and 3. Hepatitis C virus RNA was demonstrated in cryoprecipitates from 21 of 24 immunoblot-positives and from 6 of 11 immunoblot-negatives, indicating an actual active viral replication in 77.1% of group 1. This was also found in 13 (86.7%) and 10 (83.3%) cryoprecipitates was the prevalent form in group 1 (88.6%) and group 2 (73.3%), whereas type III was found in group 3 (58.3%) and in 26.7% of group 2. Type I cryoglobulins were found only in group 1 and were negative for hepatitis C virus antibodies and RNA. Hepatitis B virus markers indicating a chronic carrier state were found in 3 patients, 2 of whom were also infected with hepatitis C. It is concluded that mixed cryoglobulinemia is very commonly associated with active hepatitis C infection. The presence of hepatitis C virions and likely virus antigen-antibody complexes in cryoprecipitates strongly suggests a causative role of this virus in the pathogenesis of tissue damage and indicates that the term “essential,” which usually defines a major proportion of types II and III cryoglobulins, should be abandoned.     

Mixed cryoglobulinemia is associated with increased risk for death, or neoplasia in HIV-1 infection

BACKGROUND: Cryoglobulinemia has been reported in several chronic infectious and autoimmune diseases, and in patients with HIV-1 infection. Cryoglobulinemia associated with hepatitis C virus infection is considered a risk factor for the development of neoplasia, especially B-cell non-Hodgkin lymphoma. This study was undertaken to investigate whether the presence of circulating cryoglobulins is associated with survival or development of neoplastic disease in HIV-1 infection. DESIGN: We evaluated 87 unselected consecutive HIV-1 infected patients for the presence of cryoglobulinemia and they were prospectively followed up for a median of 34 months, with clinic visits at 4-month intervals. None of the patients had neoplasia at study entry. Time-to-event analysis for death, neoplasm and B-cell lymphoproliferative disorder were performed with Cox proportional hazards models. RESULTS: Mixed cryoglobulinemia (types II and III) was detected in 24 (28%) of the 87 patients. During the follow up, 12 patients died and 8 developed neoplastic disease. Multivariate analysis showed that circulating cryoglobulins were an independent predictor of death [relative risk (RR), 4.97; 95% confidence intervals (CI), 1.26-19.63] and development of neoplasia (RR, 5.18; 95% CI, 1.23-21.83). In addition, cryoglobulinemia reached borderline significance as a predictor of lymphoproliferative disorder of B-cell origin (P = 0.08; RR, 4.53; 95% CI, 0.83-24.75). CONCLUSIONS: Our results suggest that cryoglobulinemia is associated with an increased risk for death, neoplasia or development of lymphoproliferative disorder of B-cell origin, in HIV-1 infected patients.     

Persistence of mixed cryoglobulinemia despite cure of hepatitis C with new oral antiviral therapy including direct-acting antiviral sofosbuvir: A case series

Objective. Obtaining a sustained virologic response (SVR) in patients with chronic hepatitis C virus (HCV) can decrease hepatic complications and be curative, however, extrahepatic manifestations including mixed cryoglobulinemia (MCN) may persist with interferon-based therapy. Our objective was to review our experience in treating patients with new oral antiviral agents and to assess common factors associated with MCN persistence despite SVR. Methods. We analyzed a case series of five patients with genotype one chronic HCV complicated by MCN who had persistence of cryoglobulins despite completion of triple therapy with oral antiviral agents (boceprivir, telaprivir or sofosbuvir). Results. Patients with cirrhosis appear to have a decreased ability to clear immune complexes. We observed that early viral response by week 8 of therapy and longer periods of undetectable virus on treatment correlated with eventual clearance of serum cryoglobulins in patients without cirrhosis. Two patients were treated with anti-B-cell agent rituximab prior to starting therapy for HCV; this did not lead to a more effective clearance of cryoglobulins. Conclusions. We suggest that a longer treatment course than the standard 24 weeks with triple therapy could aid in the clearance of these immune complexes and cryoglobulins in cirrhotics. More studies to determine the ideal duration of treatment for chronic HCV and coincident MCN are needed, especially in light of the new all oral direct-acting antiviral regimens that are now recommended for HCV treatment.     

Cryoglobulinemia in Sj?gren's syndrome

As many as 130 patients with Sj?gren's disease (SD) were examined for blood cryoglobulins during 1977-1982. Cryoglobulinemia was discovered in 25 (19.2%) patients with SD. The clinical manifestations such as severe xerostomia, appreciable increase of the parotid salivary glands, hepatosplenomegaly, purpura, polyneuropathy, lesions of the lungs and kidneys were mostly detectable in SD patients with cryoglobulinemia. Ten cryoprecipitates of SD patients with cryoglobulinemia showed the monoclonal immunoglobulins IgMk-9 and IgA-1. All the patients had high titers of antinuclear antibodies and 90% manifested antinuclear Ro/La antibodies. Over the 5-year period. SD patients with cryoglobulinemia manifested the growth of hepatosplenomegaly, ulcerous-necrotic vasculitis, polyneuropathy, polyneuritis, cerebral vasculitis, lesions of the lungs and kidneys. The development of the grave systemic manifestations of the disease was attended by a decrease of immunological activity and the rise of inflammatory activity. The 5-year survival of SD patients with cryoglobulinemia was 64% against 98% in SD patients without cryoglobulinemia (p less than 0.001).     

Double-filtration plasmapheresis in the treatment of leg ulcers in cryoglobulinemia

Hepatitis C virus (HCV) is the major cause of cryoglobulinemia. Skin lesions are frequent and can be cured from the removal of cryoglobulins by therapeutic apheresis. We describe a case of HCV-positive type I cryoglobulinemia with severe leg ulcers, not responsive to antiviral and immunosuppressive treatment. Thirty sessions of double filtration plasmapheresis were performed, over a period of 6 months, with no other associated treatment. Before and after each session an assessment of immunoglobulins, complement, cryocrit, and fibrinogen was made. HCV RNA levels were determined in serum cryoprecipitate, supernatant before and after each session, and in the collection bag. No differences in pre and postapheresis values were observed in the serum concentrations and the supernatant, whereas the postapheresis cryoprecipitate showed a significantly reduced viral load (P < 0.02) as compared with the preapheresis values. There was improvement in the condition of ulcers in the leg during apheresis and had completely regressed by the end of the cycle.     

Liver involvement in essential mixed cryoglobulinemia

Summary Twenty-one of 30 patients with essential mixed cryoglobulinemia (EMC) had evidence of liver involvement. The liver disease was characterized by the absence of clinical symptoms, hepatosplenomegaly, mild elevation of enzymes, abnormal BSP retention and low albumin levels. Histology, available in 12 patients, showed either chronic persistent or chronic active hepatitis or liver cirrhosis; 44% of the patients had HBsAg or HBsAb in sera and/or cryoglobulins, confirming the high frequency of exposure to hepatitis B virus (HBV) infection in EMC. However, liver lesions were similar in all patients, regardless of HBV exposure. Since other factors usually associated with chronic liver diseases were absent or apparently irrelevant, it is temptative to speculate that a ‘cryoglobulinemic hepatitis’ may exist as a distinct syndrome. The characteristic complement profile of the patients with EMC (low CH₅₀ and C4, normal C3PA), not related to albumin levels, can help to differentiate this disease from chronic liver disease without cryoglobulins. A preliminary report of this work was presented at the XIV International Congress of Rheumatology, San Francisco, Calif., USA, on June 27, 1977.     

Cryoglobulins in acute experimental immune complex glomerulonephritis.

The relationship between cold-insoluble complexes, or cryoglobulins, and renal disease was studied in rabbits with acute serum sickness produced with BSA. The onset of serum creatinine elevation correlated well with the appearance of cryoglobulins. The average interval between the appearance of cryoglobulins and the elevation in serum creatinine was 0.87 day. In no animal did creatinine elevation precede cryoglobulinemia, even though immune complexes were detectable much earlier by other methods. The level of cryoglobulin correlated significantly with the level of serum creatinine (r = 0.71, p less than 0.01). Cryoglobulins may be of immunopathologic significance in acute experimental immune complex glomerulonephritis.     

Cryoglobulinemia and fibronectin in systemic lupus erythematosus

EIA was used to measure the concentration of fibronectin in plasma and cryoprecipitates of 37 patients suffering from systemic lupus erythematosus coupled with cryoglobulinemia. A definite relationship was discovered between the level of cryoglobulins and the activity of SLE, the concentration of fibronectin in plasma and liver damage. A tendency was revealed towards increase of the fibronectin content in plasma of patients with a high level of antibodies to native DNA and CIC as was a significant correlation between the concentration of cryoglobulin protein and the concentration of fibronectin in cryoprecipitates.     

Characterization of cryoglobulins by immunoblotting.

We adapted an immunoblotting technique for the immunochemical characterization of cryoglobulins. We first compared the results from 157 samples with results obtained by immunofixation and immunoelectrophoresis and then with clinical observations in 125 cases. Full identification was possible in 98% of the cases by immunoblotting, in 54% by immunofixation, and in 28% by immunoelectrophoresis. Novel microheterogeneity aspects were observed by immunoblotting and immunofixation in 13% and 6% of the cases studied, respectively. Our results confirm the frequency of autoimmune and infectious diseases associated with mixed cryoglobulinemias, whereas a lymphoproliferative syndrome was observed only in cases of cryoglobulinemia with a monoclonal constituent or a microheterogeneity aspect, which was not always revealed by immunofixation or immunoelectrophoresis. The pathophysiological importance and classification of microheterogeneity aspects is not clear. These observations justify using a sensitive and specific method for identifying cryoglobulins, even when present at low concentrations, and call for long-term studies of these patients.     

Pulse therapy in the complex treatment of severe forms of Sj?gren's syndrome and disease

Ten patients with Sj?gren's disease and 5 patients with systemic lupus erythematosus combined with Sj?gren's syndrome received therapy with high doses of 6-methylprednisolone (pulse-therapy) and cyclophosphamide. Improvement of the stomatological signs of the disease was noted in all the patients: salivation increased, the parotid glands considerably decreased in size, parotiditis recurrences were absent or seldom, and the number of the functioning salivary glands of the lower lip increased. The above therapy showed a positive effect on ophthalmological symptoms of the disease in 5 patients. Combination therapy (6-MP and CP) was effective for the management of such systemic symptoms of SD and SS as arthritis, lymphadenopathy, hepatosplenomegaly, exudative polyserositis, polyneuritis, ulcerative-necrotic vasculitis, cerebrovasculitis, cryoglobulinemic purpura and glomerulonephritis. A significant decrease in the levels of immunoglobulins especially IgA, A-nDNA, cryoglobulins, titers of rheumatoid factors, circulating immune complexes and an increase in the complement were noted in response to therapy.     

Role of therapeutic plasma exchanges in systemic vasculitis

Therapeutic management of systemic vasculitides is based on glucocorticoids (GCs), in combination or not with immunosuppressive and/or immunomodulatory agents. Plasma exchange (PLEX) has been used in some vasculitides, with various levels of evidence. Indeed, it is part of the first-line therapy in patients with anti-glomerular basement membrane (GBM) antibodies and in patients with severe hepatitis B related polyarteritis nodosa (PAN). PLEX might also be considered in some selected patients with ANCA-associated vasculitis and cryoglobulinemia vasculitis. Studies support the use of PLEX as second line therapy in refractory Kawasaki disease. Finally, there is not robust data to support the use of PLEX in unselected patients with non-HBV-related PAN or IgA vasculitis. Additional studies are required to address its role in these settings.     

Cryoimmunoglobulinemia in rheumatoid arthritis. Significance in serum of patients with rheumatoid vasculitis.

Cryogloculins were examined in a standardized manner in an unselected group of 35 patients with rheumatoid arthritis (RA) and 8 patients with RA complicated by cutaneous vasuclitis and neuropathy. Optimum conditions for detection and characterization of cryoglobulins were established; the proportion of resolubilized to total precipitable protein remained constant in an individual patient under these conditions. All 8 vascultis patients and 9 of 35 other patients with RA exhibited cryoglobulins; total protein and immunoglobin content were significantly higher in the cryoglobulins of patients with vasculitis. Immunoglobulins G and M constituted two-thirds and three-quarters of the total protein in the cryoglobulins from uncomplicated rheumatoid and vasculitis patients, respectively. Serum antiglobulin titers were higher, and serum C3 levels were lower, in vasculitis patients compared to rheumatoid patients without vasclitis. Anti-gamma globulin activity was detected in all cryoglobulins from vasculitis patients. Cryoglobulin IgG and IgM were polyclonal. Density gradient analyses demonstrated the majority of the cryoglobulin activity to reside in the 19S IgM fraction. There was no evidence of a light weight (8S) IgM. A monoclonal rheumatoid factor did not detect 7S-ANTI-7S complexes in the cryoprecipitates, but acid eluates from some cryoglobulins absorbed with insoluble IgG revealed an antiglobulin of the IgG class. Serial studies performed on vasculitis patients treated with cyclophosphamide disclosed a relationship between clinical evidence of vasculitis and the presence of cryoglobulins. The antigen (IgG) and antibody (largely IgM rheumatoid factor) nature of these cryglobulins is presented as evidence that the widespread vascular complications of RA are mediated, at least in part, by circulating immune complexes.     

Monoclonal cryoglobulins in primary Sj?gren's syndrome

Cryoglobulins were studied in the sera of 40 unselected pSS patients. The nature of the cryoglobulins was defined using a very fast and sensitive resolution electrophoresis technique combined with immunofixation. Thirty-five per cent of SS patients were shown to have circulating IgMk mixed monoclonal cryoglobulins. On the contrary, all the other tested cryoprecipitates were found to be mixed polyclonal, with the exception of one patient with SLE. The presence of cryoglobulins in the sera of SS patients correlated with extraglandular disease and with autoantibodies to Ro (SSA) cellular antigen and rheumatoid factor. Patients with cryoglobulins had lower serum C4 levels compared to patients without cryoglobulins. These findings suggest that SS in addition to polyclonal B-cell hyperreactivity expresses a monoclonal process preceding the development of lymphoid neoplasia. Extraglandular manifestations of the syndrome may be associated with an immune complex mediated pathology.     

Clinical and immunological aspects of cutaneous vasculitis.

Thirty-five patients with cutaneous vasculitis were studied. Sixteen had raised serum levels of cryoglobulins. In all but one the cryoglobulin was an immune complex. Eleven patients had anticomplementary sera and five had a low serum IgM. Clinically, the cryoglobulinaemic patients were not readily distinguishable from the non-cryoglobulinaemic in that cold sensitivity occurred in only six of sixteen patients with cryoglobulins. Peripheral neuropathy and lesions in the upper respiratory tract were confined to those with cryoglobulinaemia. An immunopathological classification for the purpuric vasculitides is suggested.     

Cascade filtration with reverse rinse of the secondary filter

With cascade filtration (CF) secondary filter plugging may render some procedures difficult, particularly with cryoglobulinemia or macroglobulinemia patients, when filters are subjected to the most consistent burden. To prevent plugging, in the initial management of seven patients with cryoglobulinemia or macroglobulinemia we employed polymethylmethacrylate secondary filters produced by Toray Industries Inc., Tokyo, with pores calculated at 0.1 micron (QS-12-70). In the subsequent sessions, when circulating macroproteins were reduced to more acceptable levels, secondary filters with pores of 0.06 micron were used (QS-12-50). The filtration efficiency of both filters was maintained throughout the procedures with reverse rinses carried out when the transmembrane pressure from the values of 80-130 mm Hg reached the values of 250 mm Hg. With this improved technique, 2.6-3.31 liters of plasma could be treated, producing adequate clinical benefits. From a laboratory point of view, the differential sieving for albumin and macroglobulins was 61% for the QS-12-50 filters and 56% for the QS-12-70 models.     

Cryofiltration apheresis in the United States.

There are approximately 2,000 cases of cryoglobulinemia reported each year in the United States. The number of cases has been and is expected to continue growing exponentially since the advent of its association with the hepatitis C virus (HCV). Cryofiltration apheresis is a specific therapy for the treatment of cryoprotein induced diseases that selectively removes cryoprecipitates. We are currently the only center in the United States performing cryofiltration apheresis. We report on 32 patients treated with over 920 cryofiltration apheresis procedures over the last 6 years under the Investigational Device Exemption of the Food and Drug Administration Office of Orphan Devices. Twenty-seven patients were treated for cryoglobulinemia. Twelve of these patients received maintenance cryofiltration apheresis at some point, and 5 patients died. Five of the 32 patients were treated for cold IgM agglutinin disease. Only 2 of these patients, having plasma positive for cryoprotein and a high titer antibody, responded to therapy. None of these patients received maintenance therapy. No complement activation was observed using the cryofilter by measuring C3a and C5a. Although cryoproteins were effectively removed from the plasma, the other vital proteins such as immunoglobulins, albumin, and fibrinogen were preserved. Therefore cryofiltration apheresis is safe and effective in treating cryoprotein induced diseases. We would like to see widespread use of this cryofilter so that all patients with cryoprotein induced diseases such as cryoglobulinemia may benefit from this procedure.     

Therapeutic apheresis: When things go wrong

Therapeutic apheresis medicine requires in-depth knowledge of physiology, disease mechanisms as well as a thorough understanding of the parameters that can be adjusted in the instrument that are used. We report two cases where critical decision making was crucial during management of patients being treated with therapeutic apheresis. Case 1 involves an adult patient with severe circulating cryoglobulins and Case 2 describes a patient with Waldenstr?m's macroglobulinemia and hyperviscosity. Both cases demonstrate the importance of readily available expert supervision of therapeutic apheresis procedures.