[Skin ulcers in rheumatoid arthritis]

The appearance of severe ulceration of the skin in patients with rheumatoid arthritis is often associated with a tendency to progression of the underlying disease, involvement of internal organs and increased mortality. In the pathogenesis of such ulceration there are multiple causes for their development, persistence and tendency to poor healing. They include localized or generalized immune complex vasculitis, treatment with anti-inflammatory drugs and their side effects following the treatment, arterial and venous insufficiency, and mechanical factors. The management of severe ulceration requires stabilization of the underlying autoimmune disease, e.g. with high doses of glucocorticosteroids or other immunosuppressive drugs or plasmapheresis. Adjuvant treatment of pain with analgesics, improvement of blood perfusion and anti-inflammatory drugs should accompany the topical therapy of ulcers. After suppression of the local inflammatory reaction surgical intervention becomes necessary in most of the patients, and vascularized muscle flaps should be used in preference to meshgrafts or split skin grafts for extensive ulceration in rheumatoid arthritis. A hopeful perspective in the treatment of severe rheumatoid arthritis might be opened up with immunotherapy using monoclonal antibodies.

[Today's apheresis therapy]

Recent apheresis therapy is developing day by day. Now we can say that we do not achieve suitable treatment without an apheresis technology. Acute and chronic renal failure, severe hepatic failure, acute necrotic pancreatitis and MOS are not able to treat without haemodialysis (HD), haemofiltration (HF) and plasma exchange (PE). Immunomodulation for immune complex diseases and removing of pathologic antibodies are controlled by this technique. In the near future, it will play an important role for controlling of xenotransplantation. LDL apheresis for hyperlipidemia is very effective in cleaning the blood, and the prevention of ASO, angina syndrome and coronary disease is discussed. LAK therapy and immune therapy using apheresis technique have been effective for cancer and it will be developed moreover. Lastly, apheresis used to prevent aging is the music of the future.

[Subacute progressive polyneuropathy syndrome in HIV infection. The efficacy of immunosuppressive treatment?]

A subacute advanced severe sensorimotor polyneuropathy developed over 6 months in a 47-year-old patient in stage 5 of an HIV infection (Walter Reed Hospital classification). Clinical examination, cranial computed tomography and spinal nuclear magnetic imaging failed to demonstrate any central nervous system complication. Cerebrospinal fluid showed a lymphocytic pleocytosis of 57/3 cells and total protein raised to 132 mg/dl as sign of an abnormal blood-brain barrier. Circulating immune complex in blood was raised to 30%. Assuming an immune-complex mediated neuropathy treatment with oral steroids was started, initially 150 mg daily. The signs of polyneuropathy regressed almost completely, even after prednisolone was discontinued. The proportion of circulating immune complexes in blood fell within 7 weeks to 10% during this treatment. It is suggested that in HIV-infected patients severe polyneuropathies may develop as part of a humoral immune reaction in which immunosuppressive treatment can be effective. Even in advanced HIV infection high-dosage and prolonged steroid treatment can be undertaken, under strictest indications, and may have impressive results.

The systemic vasculitides

Taken together, the systemic vasculitides constitute a small but significant component in the practice of many primary care physicians. Like most diseases with autoimmune aspects, the vasculitides increase in prevalence with age. Of paramount importance is careful differentiation, to provide early appropriate treatment and to monitor adverse effects.

Intravenous gamma-globulin therapy in systemic lupus erythematosus and immune complex disease

Immune complexes (ICs) are felt to be of primary pathological importance in the mediation of many human glomerular diseases. This is based on the demonstration of Ig and C' in renal cortex tissue of affected individuals. Systemic lupus erythematosus (SLE) is a prototype IC disease where ICs have been demonstrated in target tissues. Moreover, glomerulonephritis (GN) is a common feature of many autoimmune and infectious diseases associated with IC generation. Current therapeutic alternatives are restricted to immunosuppressive agents. Tomino et al. (Clin. Exp. Immunol. 58, 42, 1984) demonstrated that glomerular IC deposits could be solubilized with HGG. Palla et al. (Clin. Nephrol. 26, 314, 1986) treated four membranous nephritis patients with IVGG and had dramatic resolution of proteinuria in three of them. Gaedlicke et al. (Blut 48, 387, 1984) reported improvement in vasculitis in one of two patients treated with IVGG. We have experienced exacerbation of GN with IVGG therapy in two SLE patients. IVGG is useful in treating the common variable immunodeficiency that occurs in some SLE patients and in treating the immunodeficiency associated with florid nephrotic syndrome. IVGG given to one patient with Henoch-Schönlein purpura resulted in the onset of gross hematuria. In sum, IVGG may be useful in treating specific IC renal diseases by solubilization of circulating or in situ ICs but definitive proof is lacking. In other situations, IVGG may exacerbate the glomerulonephritis, possibly through enhanced IC formation. Furthermore, IVGG may induce modulation of immune responses by induction of auto-anti-idiotypic immunity.

Cisplatin-associated hemolytic-uremic syndrome. Successful treatment with a staphylococcal protein A column

Cisplatin-associated hemolytic-uremic syndrome (HUS), an under-reported form of HUS induced by chemotherapy, typically pursues a fulminant and lethal course. We report the cases of two patients with squamous cell carcinoma of the head and neck who developed massive hemolysis, profound thrombocytopenia, and dialysis-dependent renal failure after therapy with cisplatin. Plasma exchange was ineffective in both patients, but plasma perfusion with a staphylococcal protein A column produced a dramatic and permanent response in the second patient. These cases show the importance of considering HUS as a cause of renal failure in such patients who receive cisplatin-based chemotherapy, and support the role of staphylococcal protein A plasma perfusion as treatment for this condition.

[Rapidly progressing glomerulonephritis. Spontaneous course and differential therapy with special reference to the infection-associated form]

Since 1971 we observed 31 patients with histologically proven rapidly progressive (crescentic) glomerulonephritis. At the onset of therapy 16 patients presented with end stage renal failure, the others with impaired renal function. 21 patients received combined immunosuppressive therapy, consisting of prednisone, cyclophosphamide and azathioprine. 8 patients were treated with membrane plasmapheresis, additionally. 10 patients received no specific therapy. After 5 years 13 patients were on hemodialysis, 4 had impaired renal function and 10 patients were dead. Two patients died due to the progression of underlying diseases, the others were lost following infectious diseases. There was no additional positive effect in the group treated with membrane plasma separation compared with patients treated only immunosuppressive. Only in 4 patients without specific therapy normalization of renal function occurred. In these patients RPGN appeared after an infectious disease. We conclude that an infectious disease associated RPGN is an own entity of glomerulonephritis that has a very good prognosis and needs only antibiotic therapy.

In vivo binding of circulating immune complexes by C3b receptors (CR1) of transfused erythrocytes

The effects of packed erythrocyte transfusion with high CR1 activity on circulating immune complex concentrations were studied in 14 transfusion experiments involving 12 patients with immune complex related diseases. Before erythrocyte transfusion circulating immune complex concentrations ranged from 8 to 128 micrograms/ml. After transfusion (2-3 units) immune complex concentrations decreased depending on the levels of CH50 titres in the recipients. In 11 experiments, in which the patients' CH50 titres ranged from 21 to 44, immune complex concentrations decreased by 75-100% within five days. The CH50 titres were also decreased after erythrocyte transfusion but subsequently increased to initial ranges within 6-35 days. In three patients with low CH50 titres (1.0-10.0) decreases in immune complexes were not observed. Direct Coombs' tests for IgG and C3 were performed before and after erythrocyte transfusion to determine potential in vivo binding of circulating immune complexes. Thus in eight of 14 experiments, in which erythrocytes carried no IgG before packed erythrocyte transfusion, seven became Coombs' positive for IgG after the transfusion. In seven of 14 experiments, in which erythrocytes were negative for complement before transfusion, five became positive afterwards. Moreover, in 12 instances slight increases of CR1 activity of patients' erythrocytes were observed within eight days, which improved further within 35 days after erythrocyte transfusion. These studies suggest that transfusion of erythrocytes with high CR1 activity results in the removal of circulating immune complexes and that this process is dependent on complement consumption. These experiments support the hypothesis that erythrocyte-CR1 has a functional role in the removal of circulating immune complexes and may thereby inhibit the deposition of immune complexes within body tissue constituents.

Down regulation of Fc receptors by IVIgG

IVIgG preparations are now widely applied for immune modulatory treatment in various forms of autoimmune and immune complex diseases. Several controlled studies clearly demonstrated the clinical efficacy of this type of treatment; the underlying pathophysiological mechanisms, however, have yet to be elucidated. Among the mechanisms suggested to play a role in this context is the interaction of gamma globulin with Fc gamma receptors (Fc gamma R) expressed in the membrane of immunocompetent cells. Our studies concentrated on these aspects and focused on possible functional consequences of IgG-Fc gamma R interaction. By using the peripheral blood monocyte as a model system for an Fc gamma R-bearing cell, we confirmed previous reports by showing differences in Fc gamma R binding and Fc gamma R modulation induced by IgG in its various forms (monomeric IgG, Polymeric IgG, immune complexes). As biological consequences of Fc gamma R modulation, changes in effector and accessory function of these cells were observed. The results presented in this brief review emphasize especially the difference between ligand-oriented Fc gamma R diffusion (induced by surface-bound IgG) and true long-term down-modulation of Fc gamma R (mediated by fluid-phase IgG polymers) and show that only the down-modulation of Fc gamma R correlated with impaired functions of the affected cell.

Renal transplantation and schistosomiasis mansoni

Eleven patients with schistosomiasis mansoni received a renal transplant. In 5 patients, the schistosomiasis was asymptomatic and had been diagnosed by routine examinations and had no relationship to nephropathy. In 4 patients, the nephropathy was suggestive of being of schistosomal origin. Three of them had symptomatic hepatosplenic schistosomiasis, and histologic studies of original kidneys disclosed chronic glomerulonephritis in 2 and membranous glomerulonephritis in 1 patient. These histologic pictures do not establish definitively the schistosomal origin of nephropathy. The other patient had membranoproliferative glomerulonephritis that recurred in the allograft, but he had intestinal schistosomiasis. This form of the disease is not considered by all as capable of inducing nephropathy. Two patients had the hallmarks of schistosomal nephropathy: hepatosplenic form and membranoproliferative glomerulonephritis. The 1st patient developed nephrotic syndrome 3 years after the transplantation, and an allograft biopsy disclosed membranoproliferative glomerulonephritis. The other patient had an uneventful outcome with good renal function and no proteinuria. An allograft biopsy performed 14 months after the transplant disclosed slight mesangial proliferation with IgM++ and C3++ in the mesangium.

Amelioration of immune complex-mediated glomerulonephritis by synthetic protease inhibitors

Proteases are involved in the pathogenesis of inflammatory diseases by participating in the activation of mediator systems and by producing proteolytic tissue injury. Homeostatic control of inflammation is accomplished in part by physiologic protease inhibitors. The authors investigated the effectiveness of a number of synthetic protease inhibitors in ameliorating the glomerular injury induced by immune complex-mediated glomerulonephritis in mice. Two amidine-type protease inhibitors, bis (5-amidino-2-benzimidazolyl)methane and 1,2-bis (5-amidino-2-benzimidazolyl)ethane, had the greatest effects. They caused a marked reduction in glomerular necrosis (P less than 0.001) but did not affect the amount or site of immune complex localization or leukocyte influx. The inhibition constants of the protease inhibitors against nine purified physiologic proteases were determined. These results were discussed in relation to the effectiveness of the protease inhibitors in reducing glomerular injury. This investigation indicates that the administration of synthetic protease inhibitors can have a beneficial effect on immune-mediated inflammatory injury.

Role of immune complexes in pathogenesis of renal disease

When judged by histological criteria, kidney tissue is practically devoid of immune tissue; as yet a broad spectrum of immunological diseases are targeted at the kidneys, especially at the glomeruli. Glomerular epithelial cells exhibit immune protein receptors and hence could clear immune complexes decorated with complement from the circulation. Alternatively, circulating immune complexes could become trapped in the glomerular filter and start off inflammatory reactions. Anti-glomerular basement membrane antibody reacts with glomeruli and causes glomerulonephritis. The present text is an analysis of the impact of immune complex formation on renal pathology and contains retrospective clinical data of our own hospital obtained on 192 patients undergoing diagnostic renal biopsy.