Novel rescue therapy for C4d-positive acute humoral renal allograft rejection

OBJECTIVE: To investigate the efficacy of immunoadsorption (IA) in combination with tacrolimus (TAC) and mycophenolate mofetil (MMF) rescue therapy for C4d-positive acute humoral rejection (AHR) of renal transplants. METHODOLOGY: Six of 185 cadaveric renal allograft recipients transplanted at our institute developed AHR over a mean period of 4.8 +/- 0.8 d after operation. The ages ranged from 35 to 51 yr (mean 42.6 +/- 5.6 yr). C4d deposits in peritubular capillaries (PTC) and accumulation of granulocytes in PTC were observed. IA with staphylococcal protein A and TAC-MMF combination therapy were given. RESULTS: After subjected to IA for 6.3 +/- 1.03 sessions combined with TAC (0.14-0.16 mg/kg/d) and MMF (1.5 g/d) therapy, renal function recovered in all the patients. The mean duration of treatment when serum creatinine decreased was 14 +/- 2.9 d. The pre-IA panel reactive antibody reactivity was as high as 50.2 +/- 6.1%, and was significantly reduced to 8.3 +/- 2.9% after IA. Repeated allograft kidney biopsy in four of six patients revealed a favorable remission of AHR. With a mean follow-up of 18.8 +/- 5.46 months, patient and allograft survival are 100%, renal function remained stable with a mean serum creatinine of 1.2 +/- 0.22 mg/dL. CONCLUSION: The optimal treatment for alloantibody-mediated AHR remains undefined. Our findings suggest that a therapeutic approach combining IA and TAC-MMF rescue has excellence to improve the outcome of AHR.     

Monoclonal antibodies against human plasma protein C and their uses for immunoaffinity chromatography

Human protein C, isolated by conventional multistep methods, was used for immunization of mice. Monoclonal antibodies were prepared and screening of antibodies to human protein C was achieved using an immunoblotting technique. Five monoclonal anti-protein C antibodies were compared as affinity ligands. Different parameters were studied (adsorption capacity, specificity of adsorption, possibility of desorption under mild conditions) and two antibodies were selected. One antibody allows preparation of highly purified protein C in a single-step procedure from a fraction of plasma containing high levels of coagulation factors whereas the other can be used for preparation of protein C deficient plasma.     

Selective apheresis of C‐reactive protein: A new therapeutic option in myocardial infarction?

Background : There is substantial evidence that C‐reactive protein (CRP) mediates secondary damage of the myocardium after acute myocardial infarction (AMI). The aim of this animal trial in pigs was to specifically deplete CRP from porcine plasma after AMI and to study possible beneficial effects of the reduced CRP concentration on the infarcted area. Methods : Ten pigs received balloon catheter‐induced myocardial infarction. CRP was depleted from five animals utilizing a new specific CRP‐adsorber, five animals served as controls. The area of infarction was analyzed by cardiovascular magnetic resonance imaging on day 1 and day 14 after AMI. Porcine CRP levels were determined by ELISA. Results : CRP‐apheresis resulted in a mean reduction of the CRP levels up to 48.3%. The area of infarction was significantly reduced by 30 ± 6% (P = 0.003) within 14 days in the treatment group, whereas it increased by 19 ± 11% (P = 0.260) in the controls. Fourteen days after infarction, the infarcted area revealed compact, transmural scars in the controls, whereas animals receiving CRP‐apheresis showed spotted scar morphology. In the interventional group, a significantly higher left ventricular ejection fraction (LVEF) was observed after 14 days as compared to the controls (57.6 ± 2.4% vs. 46.4 ± 2.7%; P = 0.007). Conclusions : In a pig model for AMI, we observed that selective CRP‐apheresis significantly reduces CRP levels and the volume of the infarction zone after AMI. Additionally, it changes the morphology of the scars and preserves cardiac output (LVEF). J. Clin. Apheresis 30:15–21, 2015. © 2014 Wiley Periodicals, Inc.     

免疫吸附治疗抗肾小球基膜抗体疾病--附5例报告

目的：探讨免疫吸附(IA)治疗对抗肾小球基膜抗体(抗—GBM)疾病患者血清抗—GBM水平的影响及其临床疗效。方法：5例抗—GBM疾病患者，4例伴有明显肺出血，1例仅有肾损害，临床均表现为急进性肾炎，SCr312—1290μmol/L。肾活检显示肾小球新月体比例26．3％—100％。血清抗-GBM抗体40．6％—203．2RU／ml。在激素治疗同时，应用葡萄球菌A蛋白吸附柱进行免疫吸附治疗，一疗程共10次，再生血浆30—60L。结果：吸附治疗10次后，3例血清抗—GBM抗体转阴，随访4个月时抗—GBM抗体仍阴性。1例吸附治疗后血清抗-GBM抗体仍阳性，但较治疗前下降62．8％，进行第二个疗程吸附后，抗—GBM抗体转阴。4例伴有肺出血患者治疗后肺出血迅速消失。4例治疗前需血液透析的患者治疗后1例摆脱透析。SCr由505μmol/L降至157μmol/L，另3例肾活检病理显示100％新月体形成者仍需维持性血液透析。1例治疗前不需血液透析者肾功能保持稳定。结论：葡萄球菌A蛋白免疫吸附能有效降低血清抗—GBM抗体水平，迅速缓解肺出血，但改善肾功能的疗效受肾脏损害程度的影响。     

Treatment of pemphigus vulgaris: part 1 – current therapies

ABSTRACT

Introduction: While biologic agents that can be used for treating pemphigus vulgaris (PV) are increasing, themajority of the world’s PV patients can afford only corticosteroids (CS) and some immunosuppressive agents (ISA).

Areas covered: The spectrum of side effects encountered when PV patients receive high-dose, long-term CS and ISA are presented based on total dose and duration of therapy. The steroid-sparing effect of individual ISA as documented in published studies and their clinical outcomes, in terms of duration of remissions, frequency of relapses and time to relapse, are presented, so that comparisons are possible. Thus, rational choices can be made for the individual patient.

Expert opinion: In 2019, the majority of PV patients globally will continue to be treated with CS and ISA. This review will help clinicians and patients become aware of when to anticipate which side effects and if possible, to prevent or avoid them. It provides guidelines to maximize the clinical benefits of ISA in inducing and maintaining remission and minimizing side effects by monitoring them.     

免疫吸附疗法治疗神经系统免疫性疾病的临床效果观察

目的：观察免疫吸附疗法（immunoadsorption,IA）治疗神经系统免疫性疾病的临床疗效和不良反应。方法：将神经系统免疫性疾病,随机分为观察组19例和对照组19例。在常规治疗的基础上观察组采用IA治疗,对照组采用传统治疗。观察治疗前后两组患者神经功能缺损恢复情况、疗效、不良反应、免疫球蛋白IgG、IgA、IgM,补体C3、补体C4、血浆总蛋白（serum total protein,STP）含量、血细胞计数的变化。结果：两组治疗均有疗效（P＆gt;0.05）。两组治疗后（除对照组IgE外）免疫球蛋白的含量均有降低（P＆gt;0.05）,观察组IgG的含量较治疗前明显降低,差异有统计学意义（P＆lt;0.01）。两组治疗前后血细胞计数无变化。结论：IA可以明显改善患者的临床症状,可能是通过降低血液中IgG的水平而起作用。     

Regenerated Cellulose-Based Hemodialyzers with Immobilized Proteins as Potential Devices for Extracorporeal Immunoadsorption Procedures: An Assessment of Protein Coupling Capacity and In Vitro Dialysis Performances

Abstract: The development of immunoadsorbents usable with whole blood should offer the potential for making significant improvements in extracorporeal immunoadsorption procedures. In contrast to traditional chromatographic media, these hemocompatible matrices could be used without requiring the previous step of the separation of blood cells and plasma. Conventional hemodialyzers seem to be particularly appropriate for such a purpose. This paper describes a feasibility study of the preparation of immunoaffinity supports, from regenerated cellulose (Cuprophan)-based dialyzers by cyanogen bromide activation and coupling of bovine serum albumin or human immunoglobin G, used as models for immunochemical ligands. Several parameters of the activation and coupling steps were studied in order to define the optimum preparation conditions. In addition, the preservation of the transport properties (clearance and ultrafiltration) of the modified hemodialyzers was evaluated in vitro to ensure that the device potentially could be used in future human therapeutic applications with no risk of massive removal of solutes and fluid from the blood. Results indicate that 150–300 mg of immunoglobulins can be immobilized per square meter of Cuprophan. Modified hemodialyzers show a slight decrease of their clearance values and a slight increase of their ultrafiltration coefficients, and thus they can be proposed as reliable carrier material for extracorporeal cleansing systems.     

Different effects of two methods of low-density lipoprotein apheresis on the coagulation and fibrinolytic systems3

Abstract. Objective. Immunoadsorption (IMA) and dextran sulfate adsorption (DSA) are two methods for selective extracorporeal elimination of low-density lipoproteins which are known as LDL apheresis. Their influence on haemostasis until now is widely unknown. Design. The effects of both LDL apheresis procedures on the coagulation and fibrinolytic systems were compared amongst five patients treated with IMA and four patients who received a DSA therapy. Subjects. All patients with severe heterozygous familial hypercholesterolaemia were participants in a long-term LDL apheresis programme with treatments every 1–2 weeks. Intervention. Combined anticoagulation with heparin and citrate in IMA, and also heparin exclusively in DSA were used for the extracorporeal circulation. Measures. Blood samples were taken immediately before and after a single LDL apheresis and five times during the weekly interval until the next therapy. Results. DSA had a significantly greater effect on standard clotting tests than IMA at the end of plasma therapy despite identical dosages of heparin. DSA caused a considerable reduction of the coagulation factors V, VIII:C, vWF:Ag, XI, XII, and prekallikrein by 48–99% at the end of apheresis treatment whereas only factor VIII:C showed a marked decrease of 72% after IMA. All abnormalities of the global coagulation tests and of most clotting factors were restored 1 day after treatment in both procedures followed by a moderate rebound phenomenon of single coagulation factors during the next few days in IMA-treated patients. Conclusion. DSA exerts a more profound effect on the coagulation system than IMA by a substantial co-elimination of various clotting factors in addition to the desired removal of atherogenic lipoproteins.     

Identification of myosin in isolated synaptic junctions

A monospecific antibody prepared against chicken gizzard myosin reacted with only one peptide corresponding to myosin heavy chain (Mr = 200,000) in gels of synaptic plasma membranes (SPM) and synaptic junctions (SJ) prepared from several species. Preadsorption of antisera with purified brain myosin eliminated antibody reactivity to SPMs and SJs. SJs were found to contain approximately 3 times the concentration of myosin found in SPMs when assayed by an indirect immunoradiometric assay. Postsynaptic density and myelin fractions contained no myosin detectable by immunoradiometric assay, antibody binding to gels, or Coomassie blue staining. The band identified as myosin in SJ fractions yielded peptide fingerprints indistinguishable from fingerprints of purified brain myosin but distinct from fingerprints of purified smooth and skeletal muscle myosins. The distribution of exogenous [¹²⁵I]myosin during subcellular fractionation indicated that myosin in isolated synaptic junctions could not have resulted from artifactual re-distribution of soluble myosin. Together these results show that a non-muscle myosin is an endogenous component of CNS asymmetric synapses.     

Treatment of chronic dilated cardiomyopathy with immunoadsorption using the staphylococcal A-agarose column: a comparison of immunoglobulin reduction using two different techniques

Auto-antibodies to myocardial antigens have been implicated in the pathogenesis of chronic dilated cardiomyopathy (DCM). A protein A immunoadsorption affinity column system was used to remove IgG antibodies, particularly IgG3. Two techniques, the standard technique (T-1) used for removal of IgG Factor VIII inhibitors and a technique (T-2) designed to enhance IgG3 removal and address issues in venous access, minimize positive fluid balance, and adverse reactions were compared. A total of four patients were treated, two patients were treated for 5 consecutive days with each technique. T-2 resulted in larger, but not significantly so, IgG3 reduction (70% and 63%) than T-1 (53% and 59%). Both techniques lowered total IgG levels by >or=93%. Because of venous access problems, 60% of T-1 procedures reached the plasma volume target versus 100% for T-2. Positive fluid balance was significantly lower for T-2 (+507 +/- 465) ml versus T-1 (+2,206 +/- 724) ml. Overall adverse event (AE) rate (T-1:16, T-2:15) was similar between the techniques but demonstrated a statistically significant difference in the types of reactions that occurred. All AE were mild in nature, common to other apheresis procedures, and were easily managed. This small study, demonstrated that a modified technique (T-2) with superior fluid balance should be used when treating DCM with the Immunosorba system.