Fibrinogen and LDL apheresis in treatment of sudden hearing loss: a randomised multicentre trial

Quo vadis haemapheresis. Current developments in haemapheresis

The techniques of haemapheresis originated in the development of centrifugal devices separating cells from plasma and later on plasma from cells. Subsequently membrane filtration was developed allowing for plasma-cell separation. The unspecificity of therapeutic plasma exchange led to the development of secondary plasma separation technologies being specific, semi-selective or selective such as adsorption, filtration or precipitation. In contrast on-line differential separation of cells is still under development. Whereas erythrocytapheresis, granulocytapheresis, lymphocytapheresis and stem cell apheresis are technically advanced, monocytapheresis may need further improvement. Also, indications such as erythrocytapheresis for the treatment of polycythaemia vera or photopheresis though being clinically effective and of considerable importance for an appropriate disease control are to some extent under debate as being either too costly or without sufficient understanding of the mechanism. Other forms of cell therapy are under development. Rheohaemapheresis as the most advanced technology of extracorporeal haemorheotherapy is a rapidly developing approach contributing to the treatment of microcirculatory diseases and tissue repair. Whereas the control of a considerable number of (auto-) antibody mediated diseases is beyond discussion, the indication of apheresis therapy for immune complex mediated diseases is quite often still under debate. Detoxification for artificial liver support advanced considerably during the last years, whereas conclusions on the efficacy of septicaemia treatment are debatable indeed. LDL-apheresis initiated in 1981 as immune apheresis is well established since 24 years, other semi-selective or unspecific procedures, allowing for the elimination of LDL-cholesterol among other plasma components are also being used. Correspondingly Lp(a) apheresis is available as a specific, highly efficient elimination procedure superior to techniques which also eliminate Lp(a). Quality control systems, more economical technologies as for instance by increasing automation, influencing the over-interpretation of evidence based medicine especially in patients with rare diseases without treatment alternative, more insight into the need of controlled clinical trials or alternatively improved diagnostic procedures are among others tools ways to expand the application of haemapheresis so far applied in cardiology, dermatology, haematology, immunology, nephrology, neurology, ophthalmology, otology, paediatrics, rheumatology, surgery and transfusion medicine.

Use of nebulized budesonide in two critical patients with hydrocarbon intoxication

Reports of acute naphtha (a petroleum distillate) intoxication, particularly those containing treatment and toxicological data, are poorly verified in the literature. Systemic steroids have not usually been advised for routine management, but no previous studies have been reported on the effects of corticosteroid inhalations. In this study, two critical pediatric patients with chemical pneumonia due to naphtha ingestion have been reported who were effectively managed with nebulized budesonide.

Apheresis for idiopathic sudden hearing loss: Reviewing the evidence

Plasmapheresis has been used for various conditions for a number of years. Recently, its application for idiopathic sudden hearing loss (ISHL) has met with increasing interest. ISHL affects about 10-20 per 100,000 persons per year, impairing not only their hearing but also their ability to interact socially and their quality of life. ISHL is thought to be a sequela of an underlying microvascular disorder caused by a local hyperviscosity syndrome in the cochlear vessels. Plasmapheresis can effectively lower plasma and whole blood viscosity, improve erythrocyte elasticity, and reduce aggregability. Thus, it may be effectively employed in the treatment of ISHL. This article will briefly outline the background against which apheresis procedures are used in the treatment of ISHL and review studies done to date. Furthermore, a broader basis for the use of apheretic applications in the treatment of ISHL will be suggested, correlating age-adjusted ISHL incidence and age-adjusted levels of macromolecular plasma proteins such as fibrinogen. In conclusion, plasmapheresis is a promising new treatment for ISHL but more basic data on ISHL, and on apheresis applications for ISHL, are needed to safely assess treatment outcomes and possible future applications.

Therapeutic Apheresis-State of the Art in the Year 2005

Therapeutic apheresis is an extracorporeal blood purification method for the treatment of diseases in which pathological proteins or cells have to be eliminated. Selective plasma processing is more efficient in pathogen removal than unselective plasma exchange and does not require a substitution fluid like albumin. This overview presents the various selective devices for the treatment of plasma (plasmapheresis) and blood cells (leukocyte apheresis). Prospective randomized trials were performed for the treatment of age-related macular degeneration (Rheopheresis), sudden hearing loss (heparin-induced lipoprotein precipitation [HELP]), rheumatoid arthritis (Prosorba), dilative cardiomyopathy (Ig-Therasorb, Immunosorba), acute-on-chronic liver failure (molecular adsorbent recirculating system [MARS]), and ulcerative colitis (Cellsorba). Prospective non-randomized controlled trials were carried out treating hypercholesterolemia (Liposorber) and crossmatch-positive recipients before kidney transplantation (Immunosorba). Uncontrolled studies were done for ABO-incompatibility in living donor kidney transplantation (KT) (Glycosorb), acute humoral rejection after KT (Immunosorba) and acute liver failure (Prometheus). According to the 2002 International Apheresis Registry covering 11428 sessions in 811 patients, 79% of the patients showed an improvement of their condition by apheresis and only a few sessions were fraught with adverse effects (AE). The major AE were blood access difficulties (3.1%) and hypotension (1.6%). In summary, therapeutic apheresis is a safe and effective procedure for the treatment of diseases refractory to drug therapy.

The use of unequal randomisation ratios in clinical trials: a review

OBJECTIVE

To examine reasons given for the use of unequal randomisation in randomised controlled trials (RCTs).

MAIN MEASURES

Setting of the trial; intervention being tested; randomisation ratio; sample size calculation; reason given for randomisation.

METHODS

Review of trials using unequal randomisation. DATABASES AND SOURCES: Cochrane library, Medline, Pub Med and Science Citation Index.

RESULTS

A total of 65 trials were identified; 56 were two-armed trials and nine trials had more than two arms. Of the two-arm trials, 50 trials recruited patients in favour of the experimental group. Various reasons for the use of unequal randomisation were given. Six studies stated that they used unequal randomisation to reduce the cost of the trial, with one screening trial limited by the availability of the intervention. Other reasons for using unequal allocation were: avoiding loss of power from drop-out or cross-over, ethics and the gaining of additional information on the treatment. Thirty seven trials papers (57%) did not state why they had used unequal randomisation and only 14 trials (22%) appeared to have taken the unequal randomisation into account in their sample size calculation.

CONCLUSION

Although unequal randomisation offers a number of advantages to trials the method is rarely used and is especially under-utilised to reduce trial costs. Unequal randomisation should be considered more in trial design especially where there are large differences between treatment costs.

Plasma dependent reduction in red blood cell aggregation after dextran sulfate low-density lipoprotein apheresis--implications for rheological studies

Red blood cell (RBC) aggregation is increased in familial hypercholesterolemia, and is reduced significantly after low density lipoprotein (LDL) apheresis. The purpose of the present study was to clarify whether this reduction depends on changes in plasma composition, RBC membrane properties, or both. RBC aggregation was determined in a computerized cell flow-properties analyzer, before and after LDL apheresis. We compared RBC aggregation in autologous plasma with aggregation in a plasma-free standard solution (0.5% of dextran 500 kDa) to define the separate contributions of plasma and cellular properties to the observed RBC aggregation. RBC aggregation in autologous plasma was reduced by 35.5% after LDL apheresis (P=0.01) but was not significantly affected when measured in dextran 500. This suggests that LDL apheresis attenuated RBC aggregation by altering plasma composition rather than RBC membrane properties. These results are relevant to the understanding of hemorheological changes which follow therapeutic apheresis in hypercholesterolemic patients.

Acute effect of rheopheresis on peripheral endothelial dysfunction in patients suffering from sudden hearing loss

Single low density lipoprotein (LDL) fibrinogen apheresis has shown beneficial effects in the treatment of patients with sudden sensorineural hearing loss (SSHL). Pathophysiologically, a microcirculatory disorder of the inner ear, probably caused by disturbed endothelial function, is discussed as a final common pathway of a variety of SSHL etiologies. Thus, we carried out a prospective pilot study on the efficacy of Rheopheresis on vascular function in these patients, embedded into an ongoing randomized controlled multicenter trial investigating the efficacy of Rheopheresis for the treatment of SSHL. Potential modulation of systemic endothelial dysfunction by Rheopheresis was examined by measuring flow-associated vasodilatation of the brachial artery (according to the criteria of the American College of Cardiology) in a small group of patients suffering from SSHL (N=6, 5m/1f, mean age 56+/-11 years) within the last 3 days. At baseline, five of the six patients with acute hearing loss showed endothelial dysfunction as evidenced by diminished flow-mediated vasodilatation (FMD<5%). After a single Rheopheresis treatment, flow-mediated vasodilatation improved significantly (from 3.9+/-3.6% to 7.2+/-2.4%, P=0.05, mean+/-SD, two-sided paired T-test). This was paralleled by a reduction in fibrinogen (364+/-216 mg/dL to 142+/-96 mg/dL, P=0.03), total cholesterol (228+/-23 to 98+/-10, P<0.0001) and LDL cholesterol levels (153+/-8 mg/dL to 83+/-23 mg/dL, P<0.01). Based on this case series we conclude that single Rheopheresis treatment might have an acute beneficial effect on endothelial dysfunction in patients suffering from SSHL.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

This paper reviews the longitudinal studies in which the association between hypertension and cognitive functioning has been explored. The findings of these studies are far from being consistent: positive, adverse, or no relationships between cognitive performance and blood pressure have been reported. In some studies, cognitive functioning was related only to systolic blood pressure, whereas in others, it was related to diastolic blood pressure alone. Most probably, the inconsistency is due to the variability in research design, the measures employed, and data management. Some of the main methodological issues are the wide range in the age of the subjects and the variability in hypertension at baseline. Length of exposure to hypertension was rarely considered, and the search for the possible effects of the different antihypertensive treatments on cognitive ability is in its infancy. Many studies seek to identify cognitively impaired elderly and do not distinguish between the different types of dementia or the different cognitive domains. Thus, the possibility that hypertension affects specific cognitive functions has not been explored. The use of subdivisions of blood pressure values may have obscured nonlinear relationship. Nevertheless, the pattern that emerges is that midlife hypertension enhances cognitive impairment later in life, but at old age, mild hypertension may increase cognitive performance. Directions for future research to further elucidate the complex relationship between age, blood pressure, and cognition are discussed.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

Both anemia and inflammation might be present in individuals with atherothrombosis. We have evaluated the eventual influence of these 2 variables on the degree of erythrocyte adhesiveness/aggregation in the peripheral blood of 583 women and 402 men with various atherothrombotic risk factors and vascular events. It turned out that both anemia and inflammation (highly sensitive C-reactive protein concentrations) influence the degree of cell adhesiveness/aggregation and that there is no interaction between them. Thus, the degree of erythrocyte adhesiveness/aggregation might have the diagnostic advantage of being enhanced in individuals with atherothrombosis who have inflammation and no anemia as well as those who have anemia and no inflammation. These findings might help to turn a phenomenon of hemorheological relevance into a diagnostic tool for the detection of individuals at risk of an acute ischemic event.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

A common mode of deep vein thrombosis prophylaxis in medical inpatients is unfractionated heparin 5000 U subcutaneously (s.q.) twice daily. We examined the evidence in favor of using this dose of heparin in this group of patients. MEDLINE was searched for studies using the words deep vein thrombosis prophylaxis and heparin. All randomized controlled trials comparing heparin and placebo or heparin and a low molecular weight heparin were used. Relative risk was 0.4 (95% confidence interval 0.22-0.73) in studies comparing heparin 5000 U s.q. b.i.d. with placebo. Relative risk was 0.28 (95% confidence interval 0.21-0.38) in studies comparing heparin 5000 units s.q. t.i.d. versus placebo. In studies comparing unfractionated heparin with enoxaparin relative risk was 1.42 (95% confidence interval 0.99-2.05). Heparin 5000 U s.q. b.i.d. is less efficacious than low molecular weight heparins and unfractionated heparin 5000 U s.q. t.i.d.

Rheopheresis for age-related macular degeneration: clinical results and putative mechanism of action

BACKGROUND

Rheopheresis is being evaluated in a clinical trial. The rationale and available results are presented.

METHODS

We reviewed the literature about the pathophysiology of age-related macular degeneration (AMD) that might support the use of rheopheresis. In addition, we reviewed the previously published results of the use of rheopheresis for AMD.

RESULTS

There appears to be a diffusion barrier caused by accumulation of cross-linked proteins known as advanced macular oxidation products (AMOPS) in AMD. Rheopheresis allows removal of uncross-linked proteins and facilitates antioxidant entry into Bruch's membrane, preventing further accumulation of AMOPS. The Multicenter Investigation of Rheopheresis for AMD (MIRA-1), an ongoing double-masked randomized trial, should determine the efficacy of rheopheresis in preventing the progression of AMD. The interim results, from an analysis of visual acuity data for 43 patients, are encouraging, confirming the potential of rheopheresis as a therapeutic option for dry AMD. The benefit was evident immediately after treatment and remained essentially stable throughout the 12-month period of evaluation. Eyes with late-stage, high-risk, dry AMD appeared to be at significant risk for substantial vision loss over the 12 months if not treated. Subgroup analysis demonstrated that the timing of rheopheresis in the course of a patient's disease may have a pronounced effect on outcome.

INTERPRETATION

There appears to be a rationale for the use of rheopheresis in AMD. Further results of the clinical trial are awaited.

Inflammation-sensitive proteins and erythrocyte aggregation in atherothrombosis

OBJECTIVE

To find the relative contribution of various inflammation-sensitive proteins including fibrinogen, immunoglobulins (IgG, IgM and IgA), ceruloplasmin and high sensitivity C-reactive protein (hs-CRP) to the induction and/or maintenance of enhanced erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors.

METHODS

The degree of erythrocyte adhesiveness/aggregation was determined by a simple slide test and image analysis. In addition, we measured various inflammation-sensitive protein levels including fibrinogen, ceruloplasmin, immunoglobulins and hs-CRP in a group of 234 individuals with atherothrombotic risk factors and healthy ones. Pearson partial correlations and multiple linear regression analysis were performed.

RESULTS

Fibrinogen was found to be the major protein contributing to the enhanced erythrocyte adhesiveness/aggregation, explaining 30% of the model. Fibrinogen and IgG together explained 32.4% of the model. Other inflammation-sensitive proteins did not reach statistical significance and were excluded from the model.

CONCLUSIONS

Among inflammation-sensitive proteins measured in our cohort, fibrinogen is the dominant contributor to erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors and healthy ones. These findings may pave the way for the development of therapeutic strategies directed at the attenuation of erythrocyte aggregability in individuals with atherothrombosis.

LDL-Apheresis Accelerates the Recovery of Nonarteritic Acute Anterior Ischemic Optic Neuropathy

Nonarteritic acute anterior ischemic optic neuropathy (NAION) is a disabling disease which impairs visual function. It is presumed to result from disturbances of microcirculation in the anterior portion of the optic nerve head due to hemodynamic factors derived from excessive blood viscosity, or restriction of the vasal lumen in hypertensive, hypercholesterolemic, diabetic patients. We aimed to determine whether acute reduction of plasma fibrinogen and serum low-density lipoprotein (LDL) cholesterol is effective for treatment of NAION. We recruited 11 patients (7 females, 4 males) with a mean age of 57.2 +/- 19.6 years. All except one of them presented risk factors for atherosclerosis. The mean values of LDL-cholesterol and fibrinogen before treatment were 144 +/- 32 mg/dL and 341 +/- 80 mg/dL, respectively. All were treated with standard therapy (prednisone, salicylate, pentoxiphyllin) and underwent three sessions of LDL-apheresis (HELP system-B Braun) that can reduce plasma LDL-cholesterol and fibrinogen by more than 50% in a very short time. In all patients we observed a drastic reduction of LDL cholesterol and fibrinogen and a clear improvement in the visual functional data. In fact, mean values of corrected vision increased from 3.7/10 +/- 3/10 to 7.9/10 +/- 2.2/10 (P = 0.002) after the third session, while the scotomatous portion of the visual field regressed after the first session, and in 5 patients further regressed after the third session. This improvement had remained stable after 3 months. Thanks to it's effect of antagonizing hemorheologic disorders of the ocular microcirculation, fibrinogen/LDL-apheresis seems to be an efficacious treatment of NAION.

New trends in specific immunoadsorption

Plasma exchange is widely accepted to remove pathogenic substances from patients' blood that cannot be eliminated otherwise like cholesterol in severe forms of familial hypercholesterolaemia or immunoglobulins and circulating immune complexes (CIC) in many autoimmune disorders. But dilution of other plasma proteins, as well as side effects and costs of substitution fluids, limit its efficiency. In immunoadsorption, the pathogen is bound specifically, generally no substitution fluids are needed and plasma can be conducted over the immunoadsorption columns as often as needed to achieve any reduction that one aims at, in some instances below the detection limit (e.g. HLA-antibodies in transplantations). The frequency of aphaereses is determined by the speed of the patients' improvement and the rebound of the eliminated substance, which can in some disorders be slowed down or stopped by concomitant immunosuppression. Generally, immunoadsorption is used in patients, where less expensive and demanding treatment options have failed, like severe hypercholesterolaemia, autoimmune disorders or hyperviscosity syndromes.

Clinical applications of long-term LDL-apheresis on and beyond refractory hypercholesterolemia

Premature coronary heart disease (CHD) can result from high LDL cholesterol levels even in the absence of any other risk factors. A striking example is found in children who have the homozygous form of familial hypercholesterolemia (FH) with extremely high levels of LDL-cholesterol, and severe atherosclerosis and CHD often develop during the first decades of life. LDL-apheresis was developed for the treatment of severe type of FH patients who are resistant to lipid-lowering drug therapy. Clinical efficacy and safety of the therapeutic tool which directly removes LDL from circulation have already been established in the treatment for refractory hypercholesterolemia in FH patients. The most recently developed method enables lipoproteins to be adsorbed directly from whole blood, using polyacrylate column. In addition to benefits derived from the stabilization or regression of arterial lesions, we highlight other possible clinical applications of LDL-apheresis. However, most of these clinical benefits came from case reports or retrospective studies. Mechanisms related these clinical improvement remain unclear, and prospective randomized controlled trials should be performed for the new clinical indications of LDL-apheresis.

Effect of dialysis modality on plasma fibrinogen concentration: A meta-analysis

BACKGROUND

Concentrations of plasma fibrinogen, a vascular risk factor, tend to be greater in patients on peritoneal dialysis (PD) than hemodialysis (HD) therapy, like concentrations of serum cholesterol, lipoprotein(a), and transthyretin, despite the substantial loss of protein during PD. Worse vascular outcome has been noted in PD patients compared with HD patients in several studies.

METHODS

In this study, the mean difference in plasma fibrinogen levels (PD-HD) was quantified by means of meta-analysis of mean differences found in 12 cohorts with both PD and HD patients (set 1; N = 630) by using a fixed-effects model and meta-analysis of mean fibrinogen values reported in 30 cohorts of patients on a single dialysis modality (set 2; 8 PD cohorts, 22 HD cohorts; N = 2,096) by using a mixed model.

RESULTS

On meta-analysis, the weighted mean difference (PD-HD) was 105 mg/dL (95% confidence interval [CI], 86 to 124 [3.1 micromol/L; 95% CI, 2.5 to 3.6]) in set 1 and 103 mg/dL (95% CI, 53 to 153 [3.0 micromol/L; 95% CI, 1.6 to 4.5) in set 2.

CONCLUSION

Like other vascular risk factors, such as cholesterol and lipoprotein(a), plasma fibrinogen level is markedly greater in PD than HD patients, with an approximate difference of 100 mg/dL [2.9 mumol/L]. Different plasma reference ranges for fibrinogen need to be defined for PD and HD patients. The mechanism for the difference and the possible role of hyperfibrinogenemia in worsening vascular disease in PD patients deserve study.

Effects of heparin-mediated extracorporeal low-density lipoprotein precipitation beyond lowering proatherogenic lipoproteins—reduction of circulating proinflammatory and procoagulatory markers

In addition to hypercholesterolemia, proinflammatory and prothrombotic markers have been suggested to play an important role in atherogenesis. We examined whether heparin-mediated extracorporeal low-density lipoprotein precipitation (HELP) therapy modulates the circulating levels of proinflammatory and prothrombotic markers. Twenty-two coronary heart disease (CHD) patients undergoing regular HELP-apheresis (18 males, 4 females, mean age 57.3 +/- 10.9 years) were enrolled in this study. A single HELP therapy treatment significantly decreased the circulating levels of high sensitivity C-reactive protein (hs-CRP), soluble vascular adhesion molecule-1 (sVCAM-1), soluble E-selectin, lipopolysaccharide binding protein (LBP), endothelin-1 (ET-1), and monocyte chemoattractant protein-1 (MCP-1) on average by 67, 37, 24, 27, 24, and 15%, respectively. Prothrombotic factors including fibrinogen, tissue factor (TF), soluble CD40 ligand (sCD40L), and homocysteine were decreased by 66, 27, 16, and 22%, respectively. In accordance with previous studies HELP therapy reduced total cholesterol, low density lipoprotein (LDL) cholesterol, and Lp(a) mass by 50, 61, and 62%, respectively. Our data suggest that simultaneous reduction of proinflammatory and prothrombotic factors together with atherogenic lipoproteins by HELP-apheresis may contribute to improvement of endothelial dysfunction and thereby inhibit progression of atherosclerotic lesions and stabilize the existing plaque.

Heparin-mediated extracorporeal low-density lipoprotein precipitation: rationale for a specific adjuvant therapy in cardiovascular disease

Various radical measures for the treatment of severe hypercholesterolemia such as partial ileal bypass, portocaval shunt, liver transplantation and plasma exchange have been tested in patients in whom drug and diet failed or were insufficient. Although effective, most of these treatments have severe side effects and are not routinely used. For hypercholesterolemic patients LDL-apheresis has proved to be the most promising and safe way as an adjuvant therapy. Several LDL-apheresis procedures with a varying degree of selectivity and efficiency have subsequently been developed. One of them is the H.E.L.P. system which was introduced in 1984 and has now been widely used. Besides the marked reduction of LDL particles by all techniques it has become apparent that only the H.E.L.P. system results in an equally significant change in hemostaseology, hemorheology and vasomotion because of its simultaneously removal of LDL, Lp(a), fibrinogen and CRP. This contribution reviews the application of the H.E.L.P. system as a valuable therapeutic tool for the treatment of various atherothrombotic and microcirculatory disorders such as prevention of early graft occlusion after coronary artery bypass grafting, treatment of peripheral vascular disease, stroke and preeclampsia.

Platelet GPIaC807T polymorphism is associated with negative outcome of sudden hearing loss

To determine the relevance of inherited prothrombotic risk factors in sudden hearing loss, we investigated 85 patients with sudden hearing loss of >/= 60 dB for the presence of inherited prothrombotic risk factors. The FV G1691A, FII G20210A, GPIa C807T, GPIIIa PIA1/A2, PAI-1 4G/5G, t-PA Alu repeat ID, MTHFR C677T and CBS 844ins68 genotypes were investigated. Allele frequencies found in patients were compared to those of 85 healthy control subjects of the same ethnic background using Chi-squared and odds-ratio analysis. The frequency of the GPIa807T allele was significantly elevated in patients compared to controls. In addition, allele frequency and genotype distribution of GPIa was significantly elevated in the patient group without recovery after 3 months of sudden hearing loss onset. Allele frequencies of all other prothrombotic risk factors investigated here did not differ from those of the control subjects. The single-nucleotide polymorphism of GPIa C807T seems to play a role as a prognostic factor in recovery from sudden hearing loss.

State of the Art of Low-density Lipoprotein Apheresis in the Year 2003

Low-density lipoprotein (LDL) apheresis is a last-resort treatment for hypercholesterolemic patients resistant to conservative lipid-lowering therapy. In the extracorporeal circuit, LDL, Lp(a) and coagulation factors are selectively eliminated, while the beneficial proteins like high-density lipoprotein, albumin and immunoglobulins are returned to the patient. Clinical effects of LDL apheresis comprise improvement of symptoms like angina and exercise tolerance, reduction of clinical coronary events like unstable angina, need for angioplasty or bypass operation, myocardial infarction and ultimately coronary mortality. The reduction of atherogenic lipoproteins and of coagulation factors by LDL apheresis (LA) positively influences hemorheology, endothelial function and coronary reserve. In the controlled LAARS, LA significantly improved the electrocardiographic signs of myocardial ischemia in the treadmill test. In angiographically controlled trials such as LARS and L-CAPS, a reduction of progression of coronary lesions was observed; in favorable cases, regression of the stenoses could be documented. In addition, in the LDL apheresis coronary morphology trial, LA decreased the coronary plaque area. The Hokuriku trial documented a 72% decrease of coronary events (MACE) in the LA group vs. controls treated only by statins. In longitudinal studies, the incidence of MACE after regular LA decreased compared with the preapheresis period in the same patients. Apart from coronary heart disease, recent studies indicate a positive effect of LA also on carotid artery stenoses and peripheral vascular disease. Prospective randomized studies showed the beneficial effects of cascade filtration on age-related macular degeneration and of heparin-induced LDL precipitation apheresis on acute inner ear deafness.

Idiopathic sudden hearing loss in patients with type 2 diabetes

The aim of the present study was to identify clinical and audiologic characteristics of idiopathic sudden hearing loss (ISHL) in patients with type 2 diabetes. We retrospectively investigated 148 cases of ISHL, whose age was more than 40 years, comparing clinical and audiologic valuables between diabetic and non-diabetic patients. Twenty-four patients (16.2%) had type 2 diabetes (16 male, 8 female). Prevalence of hypertension and hyperlipidemia were significantly greater in diabetic patients. Hearing in the affected ear was more impaired in diabetic than non-diabetic patients, although hearing in the unaffected ear and degree of recovery did not differ significantly. Mean BMI, duration of diabetes, HbA1c values, and ultrasonographically determined carotid intima-media thickness (IMT) and plaque scores in diabetic patients with ISHL were 24.0+/-3.7 kg/m(2), 9.8+/-7.8 years, 7.8+/-1.5%, 0.83+/-0.16 mm, and 3.8+/-2.8, respectively. Of 17 diabetic patients whose ISHL was treated with steroids, 12 required insulin for glycemic control during treatment. Compared with diabetic patients without ISHL, HbA1c value was significantly higher in diabetic patients with ISHL (7.2+/-1.2% versus 7.8+/-1.5%, P=0.0202). In conclusion, nearly 16% of our patients with ISHL had type 2 diabetes, and this subgroup was associated with more severe hearing loss. Further studies are needed to determine which subgroups of diabetic patients are most likely to develop ISHL, which patients are predisposed to more severe hearing loss, and how various factors and treatments influence outcome.

Sex differences in the expression of haemorheological determinants in individuals with atherothrombotic risk factors and in apparently healthy people

BACKGROUND

Increased red cell aggregation can be detrimental, leading to slow capillary blood flow and tissue hypoxaemia. Sex differences in the degree of erythrocyte adhesiveness/aggregation in the peripheral blood have not been clearly shown.

OBJECTIVES

To determine whether there are sex differences in the expression of erythrocyte adhesiveness/aggregation in the peripheral blood in individuals with atherothrombotic risk factors and in apparently healthy people.

METHODS

From a cohort of 965 participants in the Tel Aviv Medical Centre inflammation survey, 192 pairs of different sex were matched for age, body mass index, hip and waist circumferences, cardiovascular risk factors, and the intake of active cardiovascular drugs.

RESULTS

Women had an enhanced degree of red cell aggregation (p < 0.0005) as well as increased concentrations of inflammation sensitive proteins including fibrinogen and C reactive protein. Women had a lower haemoglobin concentration than men, but this did not affect the degree of erythrocyte adhesiveness/aggregation.

CONCLUSIONS

The significant increase in red blood cell adhesiveness/aggregation in the peripheral blood of women with atherothrombosis could be relevant to the more eventful course that some women experience during and following acute ischaemic disease.

Comparative Analysis Between Dextran Sulfate Adsorption and Direct Adsorption of Lipoproteins in their Capability to Reduce Erythrocyte Adhesiveness/Aggregation in the Peripheral Blood

The purpose of this study was to compare the degree of erythrocyte adhesiveness/aggregation (EAA) reduction of two low-density lipoprotein (LDL) apheretic procedures, namely direct adsorption of lipoproteins (DALI) and dextran sulfate adsorption (DSA). A significant (P < 0.001) reduction of EAA was noted in six hypercholesterolemic patients who underwent a total of 40 apheretic sessions and no difference was noted in the degree of EAA reduction by the two techniques. Thus. being a real-time and point-of-care test, the erythrocyte adhesiveness/aggregation test can be applied in relevant situations of acute ischemia, where therapeutic LDL apheresis could improve the hemorheology of individuals with increased concentrations of cholesterol and inflammatory sensitive proteins.

The Efficacy and Safety of the New Heparin-induced Extracorporeal Low-density Lipoprotein Precipitation System (Plasmat Futura) in Comparison with the Currently used System (Plasmat Secura)

The aim of the present study was to examine whether the recently introduced heparin-mediated extra-corporeal low-density lipoprotein precipitation (HELP) apheresis system Plasmat Futura (since 2001) was comparable to Plasmat Secura system, used to date, in its efficiency to remove atherogenic components, its ease of handling and operating as well as clinical safety and patient compliance. Coronary heart disease (CHD) patients (N = 21) were first treated with Plasmat Secura system and 13 of them were then randomly switched over to the upgraded Plasmat Futura system. Eight patients remained on Secura system. All together, 40 Futura treatments and 40 Secura treatments were performed. Blood samples were collected immediately before and after each apheresis therapy. Our data showed no significant differences in the reduction of plasma low-density lipoprotein, lipoprotein (a) and fibrinogen by Plasmat Futura and Secura system (P > 0.05). However, the major advantages of Plasmat Futura system are the ready-to-use sterile dialysis solutions instead of reverse osmosis device in Plasmat Secura, which ensures flexibility and lower risk of cross infections. Long-term tolerance and safety parameters showed no significant difference (P > 0.05). On the basis of our studies. Plasmat Futura system is easy to use, shows no adverse events and is comparable to Plasmat Secura in its capacity to remove proatherogenic plasma factors.

The degree of red blood cell aggregation on peripheral blood glass slides corresponds to inter-erythrocyte cohesive forces in laminar flow

OBJECTIVE

To determine the degree of correlation between red blood cell (RBC) aggregation on peripheral blood glass slides (PBGS) as determined by image analysis and the inter-erythrocytic cohesive forces as determined in a computerized cell flow properties analyzer (CFA).

STUDY DESIGN

RBC aggregation was assessed using both systems simultaneously in healthy volunteers, obese patients and hypercholesterolemic individuals before and following LDL apheresis.

RESULTS

A significant (r = 0.5, p < 0.001) correlation was noted between the flow-dependent average aggregate size (AAS) obtained in the CFA and the degree of RBC aggregation on peripheral blood glass slides. Moreover, the enhanced RBC aggregation on the slides was positively associated with the appearance of larger aggregates in the CFA (r = 0.5, p < 0.001) and inversely with the formation of smaller aggregates (r = -0.27, p < 0.04). A similar reduction in RBC aggregation following LDL apheresis was noted in both systems.

CONCLUSIONS

The phenomenon of RBC aggregation on peripheral blood glass slides is governed by significant inter-erythrocytic cohesive forces and is not a result of a mere coincidental superimposition of cells. The slide test offers a rapid and simple method of evaluating rheologically significant RBC aggregation, and may allow stratification of patients at risk for atherothrombosis.

Acute hearing loss

Acute hearing loss (AHL) is a medical urgency. The management of patients presenting with sudden deafness involves detecting the causal mechanism and administering emergency therapeutic drugs to restore hearing by minimizing the period of cellular ischemia to the inner ear. Acute management of AHL consists of administering a 10-day course of high-dose corticosteroids (prednisone 60 to 80 mg) until a cause can be established. Magnetic resonance imaging with gadolinium is indicated, with a study dedicated to the internal auditory canals. The natural history of idiopathic AHL is characterized by spontaneous improvement in two thirds of patients. Maximum improvement occurs within 2 weeks of onset of AHL. In the vast majority of patients (>90%), the AHL is idiopathic. For an identifiable etiology, the treatment is specific and may consist of stopping ototoxic medications, repair of perilymphatic fistulas, administering antimicrobial agents for viral or bacterial infections, correction of metabolic imbalances, management of stroke, and possible surgery for cerebellopontine angle tumors. Management of idiopathic AHL is controversial. Various therapeutic agents, such as vasodilators, diuretics, anticoagulants, plasma expanders, contrast agents, and carbogen inhalation, have been tried in single therapy or as a combination therapy. The empiric use of these drugs is mainly based on improving the blood circulation and restoring the oxygen tension to the inner ear. The use of interventional procedures, such as low-density lipoprotein apheresis as well as newer drug delivery systems for corticosteroids, and immunosuppressive agents have opened new options in the treatment of AHL secondary to immune-mediated diseases of the inner ear. Prognosis for AHL is best when patients are seen early, begin recovery within 2 weeks, and have a mild hearing loss (<90 dB) with upward-sloping audiograms. Greater than 90 dB of hearing loss along with flat or down sloping audiogram, advanced age, and presence of vertigo are adverse prognostic factors for recovery of hearing loss.

Improved treatment of sudden hearing loss by specific fibrinogen aphaeresis

The etiology of sudden sensorineural hearing loss is still unclear and is thought to result from disturbances of microcirculation, infectious causes, or autoimmune disorders. So far standard therapy did not show clear improvement over spontaneous remission rate, which is assumed to be about 50% [Nakashima et al., Acta. Otolaryngol. Stockh. 514:14-16, 1994; Schuknecht and Donovan, Arch. Otorhinolaryngol. 243:1-15, 1986; Harris and Sharp, Laryngoscope 100:516-524, 1990; Mayot et al., Clin. Immunol. Immunopath. 68:41-45, 1993; Gussen, Ann. Otol. Rhinol. Laryngol. 85:94-100, 1976]. Elevated blood viscosity due to high fibrinogen levels is supposed to cause decreased cochlear blood flow and thus initiate sudden hearing loss. The specific lowering of fibrinogen immediately decreases plasma viscosity exactly to the desired extent and should lead to improved cochlear blood flow [Suckfüll et al., Acta. Otolaryngol 119:763-766, 1999; Suckfüll, Lancet 360:1811-1817, 2002; Walch et al., Laryngol. Rhino. Otol. 75:641-645, 1996; Suckfüll et al., Otol. Neurotol. 23:309-311, 2002]. In a prospective uncontrolled pilot study on 36 patients with unilateral sudden onset sensorineural hearing loss (SHL) we tried to establish that 1-3 specific fibrinogen aphaereses alone improve recovery of hearing and that it is possible to lower fibrinogen to the target of 80-100 mg/dl without important side effects. Pure tone audiometry was carried out immediately before and after each aphaeresis as well as at 2 and 4 weeks and 6 months after treatment. Sixteen patients recovered spontaneously before undergoing fibrinogen adsorption. All 20 aphaeresis patients improved during immunoadsorption; in 60% of patients auditory thresholds returned to normal after the first immunoadsorption and treatment could be discontinued, in another 20% of patients complete recovery was reached after 4 weeks. The mean plasma fibrinogen concentration of the 20 patients before the first aphaeresis session was 308.1 +/- 51.5 mg/dl. Immediately after the first treatment session, the fibrinogen concentration was lowered to 100.7 +/- 25.3 mg/dl (P < 0.001). The second and third sessions also showed highly significant reductions in plasma fibrinogen. No important side effects were seen. In conclusion, specific fibrinogen adsorption is a promising new treatment modality that should be tested in a prospective, randomized controlled trial in patients with sudden hearing loss.

Significant dominance of fibrinogen over immunoglobulins, C-reactive protein, cholesterol and triglycerides in maintaining increased red blood cell adhesiveness/aggregation in the peripheral venous blood: a model in hypercholesterolaemic patients

BACKGROUND

It is not clear what is the relative importance of fibrinogen, immunoglobulins, highly sensitive C-reactive protein (hs-CRP), cholesterol and triglyceride concentrations on the appearance of aggregated red blood cells in the peripheral blood.

DESIGN

Six hypercholesterolaemic patients undergoing regular LDL apheresis that were examined repeatedly before and following the procedure.

RESULTS

We determined the degree of erythrocyte adhesiveness/aggregation in relation to the concentration of the above-mentioned macromolecules in 80 samples. In a linear logistic regression the respective R2 values for fibrinogen, total cholesterol, triglycerides, hs-CRP, IgG, IgM and IgA were 0.45 (P<0.0001), 0.2 (P<0.0001), 0.02 (P=0.02), 0.001 (P=NS) and 0.002 (P=NS), respectively. We further analyzed the potential of ApoA, ApoB and Lpa to participate in red cell adhesiveness/aggregation and found them to be not significant.

CONCLUSIONS

In a milieu of adhesive macromolecules, lipids and inflammation-sensitive proteins including fibrinogen, total cholesterol, triglycerides, hs-CRP and immunoglobins G, M and A, fibrinogen has a dominant role in maintaining the red blood cell adhesiveness/aggregation in the peripheral venous blood. These findings are relevant for the research directed at finding new apheretic modalities to reduce the degree of red blood cell adhesiveness/aggregation in the peripheral blood.

Is there a need for a national or a global apheresis registry?

Indications for apheresis may vary and more than 45 different diagnoses have been reported from various countries. New devices are being developed and, in the beginning their clinical implications and use are limited to detect rare but important side effects. However, to achieve more reliable information on the effects and side effects we need more extensive sampling of data. Collection of such data is considered a safety and quality issue in several countries. However, data is still limited and little is known about therapeutic apheresis practised around the world including the incidence and pattern of adverse events. The establishment of national registries and analyses of data on a global level therefore seems important. Thus the World Apheresis Association (WAA) has initiated a global apheresis registry for therapeutic procedures and collection of e.g., stem cells. The WAA registry is Internet based and the site is at www.iml.umu.se/medicin. A login code to test the registry is needed (AL61TMS). This report deals with the aim of a global registry as well as some comparative data regarding findings of the Canadian, French and Swedish registries.

Clinical studies to implement Rheopheresis for age-related macular degeneration guided by evidence-based-medicine

In the majority of age-related macular degeneration (AMD) patients the therapeutic situation is very unsatisfactory, especially for patients with dry AMD. Rheopheresis is a safe and effective modality of therapeutic apheresis to treat microcirculatory disorders, and represents a novel therapeutic approach for patients with dry AMD and soft drusen. Elimination of a defined spectrum of high molecular weight proteins from human plasma including pathophysiologically relevant risk factors for AMD such as fibrinogen, LDL-cholesterol, alpha 2-macroglobulin, fibronectin, and von-Willebrand factor results in the reduction of blood and plasma viscosity as well as erythrocyte and thrombocyte aggregation. Pulses of lowering blood and plasma viscosity performed as series of Rheopheresis treatments lead to rapid changes of blood flow, subsequently inducing sustained improvement of microcirculation, and recovery of retinal function. Two controlled randomized clinical trials demonstrated safety and efficacy of Rheopheresis for the treatment of AMD patients, especially with the dry form. Recently the interim-analysis of the sham-controlled, double blinded, randomized multicenter MIRA-I trial confirmed these results. The RheoNet-registry and the development and continuous update of therapy guidelines provide an appropriate framework for the quality management of the interdisciplinary cooperation between ophthalmologists with apheresis specialists. A hypothesis based upon current knowledge of pathogenic mechanisms of the development and progression of AMD can be conclusively linked with the putative mechanism of action of Rheopheresis for AMD. A recommendation for high-risk AMD-patients was defined. Based on the positive results of the MIRA-1 interim analysis eight Rheopheresis treatments are currently recommended as the initial treatment series.

The HELP system for the treatment of atherothrombotic disorders: a review

Given the importance of atherothrombotic disorders for the public health system, and the known limitations of conventional treatment on one hand and the compelling biochemical evidence and long-term safety of HELP (Heparin-mediated Extracorporeal LDL/Fibrinogen Precipitation) apheresis on the other hand, this approach provides a most valuable tool for further medical research and treatment of the various atherothrombotic and microcirculatory disorders. The present contribution reviews the recent developments in chronic and single application of apheresis in cardiology with particular emphasis on the newly discovered therapeutic possibilities for myocardial infarction, stroke, and after coronary artery bypass grafting.