Apheresis Technologies: An International Perspective

Abstract: The developments in apheresis techniques and their clinical applications world-wide are technologically driven. In the past, apheresis survey statistics have highlighted both the differences by region in clinical practice and in the types of technologies utilized. Such differences have provided a basis for the scientific and clinical assessments of these apheresis technologies and their clinical outcomes and have stimulated the marketing and business development of new technologies world-wide. A review of the regional practices and technologies utilized provides a perspective on the future role of apheresis and its developments in clinical practice. While technology is a driving force for the development of new techniques for clinical practice, it is not the only market force. For technology introduction, several other important issues need to be considered. Regulations at the local and, most importantly, the federal level impact the timing for new technology introduction. Reimbursement by healthcare payers is critically important from the initiation of the development of a technology through its clinical use. Clinical trials are critically important to show the safety and clinical- and cost-effectiveness of the technology in order for payers to provide reimbursement for its use, but these trials are sometimes long and costly. Research funding availability at the governmental and commercial levels critically impacts new technology investigation and its introduction. Apheresis technology developments offer new hopes and promises for the clinical team; however, their development, introduction, and utilization will be influenced by the prevailing market forces.     

Expression of cell-matrix molecules and integrin receptors in human liver grafts during chronic rejection

Abstract The inflammatory response of immune cells to target cells and cell-matrix molecules is regulated by several receptor-ligand molecules. As fibrosis develops in ongoing chronic rejection after liver transplantation, it is of interest to analyze patterns of integrin receptors and cell-matrix molecules in order to study the relation between immune cells and the stromal and parenchymal cells. In the present study, we demonstrated the expression of these molecules in chronic rejected human liver grafts using immunohistochemical techniques. The results showed a differential expression and induction of integrin receptors and cell-matrix molecules on resident liver cells, especially on sinusoids, reflecting a state of chronic inflammation and a specific interaction between integrin receptors and cell-matrix molecules. The patterns of induced integrin receptors on graft-infiltrating cells was closely related to the local production of cell-matrix molecules and reflected the final sequence of a stepwise progress of the inflammatory reaction.     

Gallstone recurrence after direct contact dissolution with methyltert-butyl ether

To determine the rate and characteristics of gallstone recurrence after direct contact dissolution with methyltert-butyl ether, 60 consecutive patients were followed for up to 4.5 years (median 2.2 years) after complete disappearance of all stone residues and debris and cessation of adjuvant bile acid therapy. Initial gallstones had been multiple in all but four patients. Twenty-eight of the 60 patients developed recurrent gallstones. The cumulative risk of gallstone recurrence (actuarial analysis) was 23±6%, 34±7%, 55±8%, and 70±9% at one, two, three, and four years, respectively. The recurrent stones were usually multiple and small (6±4 mm). Gallstone recurrence was associated with recurrent biliary pain in two patients, one of whom developed acute cholecystitis. Recurrent stones were cleared completely by bile acid medication with or without shock-wave lithotripsy in 61±15% of patients at one year (actuarial analysis). In conclusion, gallstone recurrence after successful contact dissolution of multiple stones with methyltert-butyl ether has to be expected in a high percentage of patients. Most patients, however, remain free of biliary pain during long-term follow-up.     

Detecting danger--or just another odorant? Olfactory sensitivity for the fox odor component 2,4,5-trimethylthiazoline in four species of mammals

2,4,5-trimethylthiazoline (TMT) is a volatile component of the anal gland secretion of the red fox and elicits behavioral and physiological fear responses in the rat. Using instrumental conditioning paradigms, we determined olfactory detection thresholds for TMT in three rats, a natural prey species of the red fox, and compared their performance to that of three squirrel monkeys, three spider monkeys and four pigtail macaques, all non-prey species of the red fox. We found that the rats were able to discriminate concentrations between 0.04 and 0.10 ppt (parts per trillion) of TMT from the odorless solvent which is by far the lowest olfactory detection threshold for an odorant reported in rats so far. In contrast, the spider monkeys needed 0.14-1.38 ppb (parts per billion), the pigtail macaques 0.41-4.07 ppb, and the squirrel monkeys 4.07-13.80 ppb to detect TMT which does not rank among the lowest olfactory thresholds reported for these three primate species. Thus, these results support the assumption that the behavioral relevance of an odorant may be an important determinant of a species' olfactory sensitivity.     

Plasmareninaktivität nach Orthostase und nach Diazoxid bei primärer und renaler Hypertonie

Zusammenfassung 1. Nach Blutdrucksenkung durch schnelle intravenöse Injektion vonDiazoxid kommt es bei 35% der Kranken mit primärem Hochdruck zu einem Anstieg der Plasmareninaktivität. Das Ausbleiben des Reninanstiegs bei der Mehrzahl der fortgeschrittenen primären Hypertonie wird, ebenso wie die abgeschwächte Stimulierbarkeit der Reninsekretion durch Natriummangel, auf eine (adaptiv) verminderte Empfindlichkeit der intrarenalen Receptoren zurückgeführt. Die Blutdrucksenkung durch Diazoxid ist bei positiv und negativ reagierenden Kranken gleich groß.2. Nach einer definiertenOrthostase von 60 min Dauer bei 70° Schräglagerung fehlt ein Plasmareninanstieg bei 63% der untersuchten Patienten mit primärer Hypertonie, wofür ebenfalls eine herabgesetzte Ansprechbarkeit intrarenaler Receptoren verantwortlich gemacht werden muß. Eine Orthostase-negative Reaktion wird ebenso wie eine solche nach Diazoxid häufiger bei primärer Hypertonie in einem fortgeschrittenem, aber auch schon in einem frühen Stadium beobachtet, in dem der Plasmareninanstieg auf Natriumentzug noch intakt ist.3. Die Reninsekretion verhält sich beiprimärer Hypertonie nach Diazoxid, Orthostase und Natriumentzug nicht übereinstimmend, was für die Existenz verschiedener intrarenaler Mechanismen spricht, die die Reninfreisetzung im iuxtaglomerulären Apparat beeinflussen. Patinten mitrenalem Hochdruck weisen dagegen ein übereinstimmendes positives oder negatives Verhalten der Reninsekretion nach Diazoxid und nach Orthostase auf.4. Für diedifferentialdiagnostische Abgrenzung einer funktionell wirksamen Nierenarterienstenose von einer primären Hypertonie ist weder der Diazoxidtest noch — ohne gleichzeitigen Natriumentzug — in der durchgeführten Versuchsanordnung der Orthostasetest geeignet. Zum Nachweis einer funktionell wirksamen Nierenarterienstenose empfiehlt sich die getrennte Plasmareninbestimmung in den Nierenvenen oder als Suchmethode die Doppelstimulation durch 3tägigen Natriumentzug und Orthostase am letzten Tag der Natriumrestriktion.

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Summary 1. After blood pressure reduction by rapid intravenous injection of diazoxide plasma renin activity is increased in 35% of primary hypertension. The absence of plasma renin increase in the majority of advanced primary hypertension is explained by an (adaptive) diminished sensibility of the intrarenal receptors. The reduction of blood pressure is equal in diazoxide responsive and unresponsive patients.2. A plasma renin increase failed in 63% of primary hypertension after upright posture by tilting to 70° for 60 minutes. This result is also explained by a diminished sensibility of the intrarenal receptors for renin secretion. An unresponsive reaction to upright posture and diazoxide is more frequent in advanced primary hypertension, but is observed also in an early stage, in which plasma renin stimulation by sodium deficiency is maintained.3. The stimulation of the renin secretion in primary hypertension is not equal after upright posture, diazoxide and sodium restriction supporting the existence of several intrarenal mechanism controlling the iuxtaglomerular apparatus. In renal hypertension on the contrary, there is a corresponding positive or negative reaction of renin secretion after diazoxide and upright posture.4. For the differential diagnosis of a functional renal artery stenosis neither the diazoxide test nor — without sodium restriction — the orthostase test is suitable. For the evidence of the functional significance of a renal artery stenosis the separated estimation of plasma renin activity in both renal veins or as a sreening test the double stimulation by sodium restriction for 3 days and upright posture is recommended.

     

The effect of dietary supplementation with n-3 polyunsaturated fatty acids on the synthesis of interleukin-1 and tumor necrosis factor by mononuclear cells

We examined whether the synthesis of interleukin-1 or tumor necrosis factor, two cytokines with potent inflammatory activities, is influenced by dietary supplementation with n-3 fatty acids. Nine healthy volunteers added 18 g of fish-oil concentrate per day to their normal Western diet for six weeks. We used a radioimmunoassay to measure interleukin-1 (IL-1 beta and IL-1 alpha) and tumor necrosis factor produced in vitro by stimulated peripheral-blood mononuclear cells. With endotoxin as a stimulus, the synthesis of IL-1 beta was suppressed from 7.4 +/- 0.9 ng per milliliter at base line to 4.2 +/- 0.5 ng per milliliter after six weeks of supplementation (43 percent decrease; P = 0.048). Ten weeks after the end of n-3 supplementation, we observed a further decrease to 2.9 +/- 0.5 ng per milliliter (61 percent decrease; P = 0.005). The production of IL-1 alpha and tumor necrosis factor responded in a similar manner. Twenty weeks after the end of supplementation, the production of IL-1 beta, IL-1 alpha, and tumor necrosis factor had returned to the presupplement level. The decreased production of interleukin-1 and tumor necrosis factor was accompanied by a decreased ratio of arachidonic acid to eicosapentaenoic acid in the membrane phospholipids of mononuclear cells. We conclude that the synthesis of IL-1 beta, IL-1 alpha, and tumor necrosis factor can be suppressed by dietary supplementation with long-chain n-3 fatty acids. The reported antiinflammatory effect of these n-3 fatty acids may be mediated in part by their inhibitory effect on the production of interleukin-1 and tumor necrosis factor.     

Up-regulation of endothelial nitric oxide synthase inhibits pulmonary leukocyte migration following lung ischemia-reperfusion in mice

Endogenous nitric oxide (NO) is known to modulate post-ischemic inflammatory response in various organs. However, the role of nitric oxide synthase isoforms (NOS) in mediating pulmonary post-ischemic inflammatory response is poorly understood. We therefore studied post-ischemic endothelial adhesion molecule expression and leukocyte migration in endothelial NOS knockout (eNOS-KO) mice subjected to pulmonary ischemia and reperfusion in vivo. Under anesthesia and mechanical ventilation, the left pulmonary hilum in wild-type (WT) and eNOS-KO mice was clamped for 1 hour, followed by reperfusion for up to 24 hours. In WT mice, we observed a selective up-regulation of both eNOS mRNA and protein in lung tissue, while inducible NOS (iNOS) and neuronal NOS (nNOS) remained unchanged. Survival in eNOS-KO mice was reduced due to severe pulmonary edema, underlining an increased susceptibility to ischemia-reperfusion (I/R) injury. Interstitial tissue infiltration by CD18- and CD11a-positive white blood cells as well as lung tissue water content peaked at 5 hours of reperfusion and were found significantly higher than in WT mice. Enhanced leukocyte-endothelial interaction was associated with pronounced up-regulation of vascular cell adhesion molecule (VCAM) in eNOS-KO mice during post-ischemic reperfusion. We conclude that eNOS attenuates post-ischemic inflammatory injury to the lung most probably via inhibition of endothelial adhesion molecule expression.     

Protective effects of PJ34, a novel, potent inhibitor of poly(ADP-ribose) polymerase (PARP) in in vitro and in vivo models of stroke

Focal cerebral ischemia activates the nuclear protein poly(ADP-ribose) polymerase (PARP) by single DNA strand breaks which leads to energy depletion and cell necrosis. Deletion or inhibition of PARP protects against ischemic brain injury. Here we examined the neuroprotective effect of PJ34, a novel potent inhibitor of PARP in vitro and in vivo. Serum-free primary neuronal cultures derived from rat cortex (E15-17) and kept in culture for 10 days were exposed to oxygen glucose deprivation (OGD) in vitro. Neuronal injury was quantified by LDH release after 24 h. Pretreatment with 30-1000 nM PJ34 significantly protected from OGD-induced cell injury in a dose-dependent manner. For in vivo experiments SV/129 mice were treated with PJ34 (50 microg) by intraperitoneal injection 2 h before 1 h middle cerebral artery occlusion (MCAo) and again 6 h later. Twenty-three h after reperfusion ischemic injury was significantly decreased compared to vehicle-treated controls (infarct volume reduction of 40%, p<0.05). Similarly, in a rat model of MCAo (2 h occlusion followed by up to 22 h reperfusion), PJ34 administration (10 mg/kg i.v.) significantly reduced infarct size, and the effect of the drug was maintained even if it was given as late as 10 min prior to reperfusion time. PJ34 significantly protected in a 4 h, but not in a 24 h permanent occlusion model. In conclusion, PJ34, a novel, potent inhibitor of PARP exerts massive neuroprotective agents, with a significant therapeutic window of opportunity. The present work strengthens the concept that pharmacological PARP inhibition may be a suitable approach for the treatment of acute stroke in man.     

In vitro production of IL 1 beta, IL 1 alpha, TNF and IL2 in healthy subjects: distribution, effect of cyclooxygenase inhibition and evidence of independent gene regulation

Numerous studies have reported altered in vitro cytokine production in various diseases. In the present study we used specific immunoassays to quantitate production of interleukin 1 beta (IL 1 beta), IL 1 alpha, tumor necrosis factor (TNF) and IL 2 from human peripheral blood mononuclear cells (PBMC). The distribution of cell-associated and secreted cytokines was studied in PBMC of 21 individuals; in response to lipopolysaccharide (LPS) the proportion of cell-associated IL 1 beta ranged from 13% to 56%, for IL 1 alpha 29% to 98%, and for TNF 2% to 17%. In a larger cohort of 32 subjects, the total amount of immunoreactive cytokines produced in response to LPS or phytohemagglutinin was normally distributed within the study group. Mean production of IL 1 alpha in response to LPS was 10.1 ng/ml and exceeded production of IL 1 beta (5.6 ng/ml) and TNF (2.2 ng/ml). The distribution pattern was characterized by high intersubject variability extending over two orders of magnitude and the presence of high and low "producers". Production of IL 1 alpha and IL 1 beta correlated (R = 0.69). In contrast, production of IL 1 beta did not correlate with production of TNF or IL 2. Indomethacin present during stimulation of PBMC increased the amount of IL 1 beta produced and showed a high correlation (R = 0.83) compared to cultures without indomethacin. Thus, low production of IL 1 beta in certain subjects appears not to be due to inhibitable levels of cyclooxygenase products. In a retrospective study, PBMC from 12 subjects who had taken oral cyclooxygenase inhibitors during the preceding 7 days produced 43% more IL 1 beta than subjects who did not take these drugs (p less than 0.05). These studies demonstrate that the amount of cytokine synthesized by PBMC (a) is regulated independently for IL 1, TNF and IL 2; (b) correlates for IL 1 beta and IL 1 alpha; (c) is intrinsic for low and high "producers", and (d) production of IL 1 beta increases with the use of oral cyclooxygenase inhibitors.