A novel bioassay to predict the clinical response to cryofiltration treatment. A preliminary report

Phagocytosis by normal human mononuclear monocytes grown in vitro was examined after incubation with known concentrations of aggregated human gamma-globulin (AHG) and in plasma obtained from patients suffering from immunologic diseases. When the phagocytes were pretreated with AHG, an inverse relationship between amounts of AHG and phagocytosis of radiolabeled Candida albicans was found. Inhibition of phagocytosis by patient plasma was independent of other laboratory determinations including antinuclear antibody, C3, C4, CH50, DNA-binding and circulating immune complexes. Plasma from 5 patients subjected to cryofiltration treatment (CFT) demonstrated less inhibition after than before CFT. This lessened inhibition of phagocytosis in vitro correlated with the clinical response due to CFT. The response to CFT could not be predicted by the conventional laboratory parameters investigated. Improvement between pre- and post-CFT plasma estimated by using the present bioassay may provide a quantitative description of which patient may benefit from plasmapheresis treatment procedures.

Removal of glomerular immune complexes in passive serum sickness nephritis by treatment in vivo with proteolytic enzymes

The effect of in vivo protease treatment on glomerular immune complex deposits was investigated in passive serum sickness in mice and rats. BALB/c mice were injected intravenously with soluble immune complexes (IC) of cationic bovine gamma-globulin (BGG) antigen and rabbit anti-BGG antibody, or IC of native BGG and rabbit antibody. One hour after receiving IC, the time of maximal deposition, the mice were treated with chymopapain and subtilisin via five intraperitoneal doses at 10-minute intervals, and they were sacrificed 20 minutes after the last treatment. Only 2 of 15 treated mice given cationic IC had capillary wall deposits of antibody versus 13 of 16 control mice (p less than 0.001); only 1 of 16 treated mice given the more neutral IC had mesangial antibody deposits versus 11 of 16 control mice (p less than 0.001). Differences in BGG antigen were not apparent. In parallel studies, soluble IC containing rabbit antibody and cationic BGG antigen were administered intravenously to rats. After 1 hour, the rats received a single intravenous dose of chymopapain and subtilisin. Ninety minutes later the rats were sacrificed. As determined by immunofluorescence microscopy only 1 of 13 enzyme-treated rats had bright capillary wall deposits of BGG antigen versus 10 of 11 control rats (p less than 0.001); only 6 of 13 treated rats had deposits of rabbit antibody versus 10 of 11 control rats (p less than 0.05). Glomeruli isolated from enzyme-treated rats that had been injected with radioactive IC contained 44% less radioactivity (p less than 0.005). These observations indicate that treatment with proteases can promote the removal of glomerular IC deposits in vivo.

Immune complex glomerulopathy in a child with food hypersensitivity

This report describes the occurrence of immune complex glomerulonephritis in a patient with eosinophilic gastroenteritis and food hypersensitivity. A coincident allergen injection may have been a contributing factor in the sudden development of the nephrotic syndrome. Markedly elevated levels of circulating immune complexes (greater than 6400 mg/dl) were found containing kappa-casein and bovine serum albumin (BSA), the latter predominating. Markedly elevated serum BSA hemagglutinating titers were also present (1:40,960). Cross-reacting precipitating antibodies to BSA, beef, and pork were demonstrated, but not to flounder or ovalbumin. Renal biopsy revealed immune complex glomerulonephritis with BSA, immunoglobulins M and G and complement deposited focally in the glomerular basement membrane. With strict dietary limitation of identified causative antigens and prednisone therapy, CIC levels decreased to 16,000 micrograms/dl and serum BSA antibody hemagglutinating titer fell 32-fold over a period of 15 months. There was prompt symptomatic relief and amelioration of signs of nephritis. The patient was able to consume a diet normal in protein and caloric content, and statural catch-up growth occurred. Recognition of food antigens to which the patient was hypersensitive provided a rationale for the relief of the gastrointestinal disturbance, growth stunting, and renal disease.

[Immunocytoma with acquired C1-esterase inhibitor deficiency and recurrent angioneurotic edema]

Four attacks of mucosal angioneurotic oedema occurred in a 57-year-old woman, requiring tracheotomy for one episode. Decreased or non-measurable levels of complement components C1q, C-1-INH and C4 pointed to a complement consumption. The basic disease was a pleomorphic immunocytoma with the production of monoclonal IgM. Treatment with danazol, 600 mg daily, raised the serum level of C-1-INH, but not of C4.

[Therapeutic separation of blood components in clinical emergency medicine]

In this paper the clinical application of component separation by means of the cell separator is demonstrated. Patients with acute intoxications, thyroid storm, plasmatic and cellular hyperviscosity syndromes, immuno-complex- and antibody mediated diseases are shown to be successfully treated on the cell separator. It is shown that the cell separator is a practicable contribution to internal medicine in the subdisciplines of clinical immunology, hematology and intensive care medicine.

Acute effect of plasma exchange on arterial blood pressure and plasma renin activity

Blood pressure (BP) decreases significantly in patients with immune complex nephritis and hypertension in the course of therapeutic plasma exchange (TPE). To investigate possible underlying mechanisms of this effect, the variations of supine and upright BP and plasma renin activity (PRA) acutely induced by PE (performed by isovolumetric replacement of plasma with 4% albumin in saline solution) were analyzed in six patients. On the average, both supine and upright BP decreased after TPE; however, statistical significance was obtained only for upright systolic BP. Supine and upright PRA did not change significantly, although a clearly blunted response to posture was observed in three patients. The changes of BP induced by TPE were apparently not due to a functional depression of the renin-angiotensin system, since the more marked decrements in BP were observed in the patients with lower basal PRA.

Hypotensive effect of plasma exchange in immune complex nephritis

The effect of plasma exchange (PE) on blood pressure (BP) in 20 hypertensive patients (9 with mixed cryoglobulinemia, 7 with systemic lupus erythematosus, and 4 with idiopathic glomerulonephritis) was evaluated retrospectively. In each PE 1.5-2.5 L of plasma was replaced with an equal volume of 4% albumin polysaline solution. The frequency of PE was three times per week for the first 2 weeks and twice per week subsequently. Sixteen patients were on hypotensive treatment at the onset of PE. Their systolic/diastolic BP was 171 +/- 4.7/102 +/- 3.0 mm Hg (mean +/- 1 SEM). After 4 weeks, BP decreased to 141 +/- 2.8/89 +/- 2.3 mm Hg (p less than 0.001), although in 10 patients antihypertensive drug therapy had been reduced or discontinued. The most marked decrease of BP occurred after the first week (152 +/- 5.3/92 +/- 2.9 mm Hg), and this decrement correlated remarkably well with pressure levels before PE despite the great heterogeneity of the individual patients (for diastolic BP, r = 0.87, p less than 0.001; for systolic BP, r = 0.60, p less than 0.01). A mild decrease of serum creatinine was observed during PE, but its time course was different from that of BP, and did not correlate with this parameter.

[Treatment of immunologic diseases using plasma separation. Proven and unproved indications]

By experienced specialists plasma separation can be applied without any serious complications. It can be expected that in future specific principles of plasmapheresis for the elimination of pathogenetic agents will be developed. Even if the exact mechanism of action of this therapeutical principle is is not yet known in all details, plasma separation is indicated as a therapeutic emergency measure in patients with autoaggressive diseases especially in case the patient is endangered by marked progression of the disease and by the failure of conservative therapy with immunosuppressive agents. So far we have treated 48 patients with 206 plasma exchanges, most ot them because of immune diseases such as systemic lupus erythematodes and immunvascultits .

Plasmapheresis combined with lymphocytapheresis and cytotoxic drugs as a therapeutic modality in neuroimmunological diseases

Rebound after plasmapheresis is thought to be due to enhanced antibody and/or immune complex production. To prevent rebound a combination of steroids and immunosuppressive drugs has been used: lymphocytapheresis was employed in most patients, for not more than 10 sessions. 50 patients with myasthenia gravis, inflammatory myopathy, chronic dysimmune polyneuropathy and immune complex polyneuropathy have been treated and long-lasting benefits obtained in 35 patients. Rebound effects were observed only when cytotoxic drugs were not given or discontinued too soon. 8 patients who had been treated by plasmapheresis combined with steroids alone, after some recurrences of their disease, were switched to cytotoxic drugs, steroids and lymphocytapheresis combined with plasma exchange: in this group 7 patients eventually gained long lasting remissions. Our clinical experience strongly supports the hypothesis of a synergy between plasmapheresis and immuno-suppressive measures.

Immune complex mediated lung haemorrhage and nephritis--successful treatment with plasma exchange, haemodialysis and immunosuppressive drug therapy

A 16-year-old boy developed an immune complex illness associated with lung haemorrhage, proliferative nephritis with crescents and renal failure. Treatment with plasma exchange, haemodialysis and immunosuppressive drugs resulted in a rapid reduction in levels of immune complexes and other mediators of inflammation and was associated with good recovery of renal and lung function. Subsequently, deterioration in renal function occurred whilst the patient was on treatment with prednisolone alone but this was reversed with a short course of plasma exchange and the addition of azathioprine. No further deterioration in renal or lung function has been observed during 18 months treatment with azathioprine and prednisolone. Immediate plasma exchange and immunosuppressive drug treatment have been recommended for Goodpasture's syndrome. Immune complex mediated lung haemorrhage and nephritis is the main clinical differential diagnosis. Our case suggests that the same treatment is effective for both conditions if given early, and that detailed renal and immunological investigations should not be allowed to delay this.

Cascade filtration: clinical application in 26 patients with immune complex and IgM mediated diseases

A new technique which allows lymphocytapheresis to be combined with cascade filtration (CF) is described in this paper. This therapeutical approach was applied for the treatment of patients affected by necrotizing vasculitis (1), inflammatory myopathies (5), Cryoglobulinemia (5), immune complex polyneuropathies (7), rheumatoid arthritis (3) and psoriasis (3 patients). Two cases of Waldenstrom's macroglobulinemia were also treated after the onset of the hyperviscosity syndrome. 78 procedures have been performed without any untoward effect. From a clinical point of view all patients had some improvement following treatment, thereby confirming not only the clinical safety of this therapeutical approach but also its effectiveness at least in the management of diseases which usually respond to plasma exchange treatment. Laboratory investigations showed that with CF it is possible to selectively remove IgM, immune complexes, fibrinogen, lipoproteins and high molecular weight plasma components, sparing most albumin and IgG globulins (85 and 71%, respectively).