1
|
Ubogu EE. Animal models of immune-mediated demyelinating polyneuropathies. Autoimmunity 2024; 57:2361745. [PMID: 38850571 PMCID: PMC11215812 DOI: 10.1080/08916934.2024.2361745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
Immune-mediated demyelinating polyneuropathies (IMDPs) are rare disorders in which dysregulated adaptive immune responses cause peripheral nerve demyelinating inflammation and axonal injury in susceptible individuals. Despite significant advances in understanding IMDP pathogenesis guided by patient data and representative mammalian models, specific therapies are lacking. Significant knowledge gaps in IMDP pathogenesis still exist, e.g. precise antigen(s) and mechanisms that initially trigger immune system activation and identification of large population disease susceptibility factors. The initial directional cues for antigen-specific effector or autoreactive leukocyte trafficking into peripheral nerves are also unknown. An overview of current animal models, with emphasis on the experimental autoimmune neuritis and spontaneous autoimmune peripheral polyneuropathy models, is provided. Insights on the initial directional cues for peripheral nerve tissue specific autoimmunity using a novel Major Histocompatibility Complex class II conditional knockout mouse strain are also discussed, suggesting an essential research tool to study cell- and time-dependent adaptive immunity in autoimmune diseases.
Collapse
Affiliation(s)
- Eroboghene E Ubogu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
2
|
Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
Collapse
Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
| |
Collapse
|
3
|
McCombe PA, Hardy TA, Nona RJ, Greer JM. Sex differences in Guillain Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and experimental autoimmune neuritis. Front Immunol 2022; 13:1038411. [PMID: 36569912 PMCID: PMC9780466 DOI: 10.3389/fimmu.2022.1038411] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Guillain Barré syndrome (GBS) and its variants, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP and its variants, are regarded as immune mediated neuropathies. Unlike in many autoimmune disorders, GBS and CIDP are more common in males than females. Sex is not a clear predictor of outcome. Experimental autoimmune neuritis (EAN) is an animal model of these diseases, but there are no studies of the effects of sex in EAN. The pathogenesis of GBS and CIDP involves immune response to non-protein antigens, antigen presentation through non-conventional T cells and, in CIDP with nodopathy, IgG4 antibody responses to antigens. There are some reported sex differences in some of these elements of the immune system and we speculate that these sex differences could contribute to the male predominance of these diseases, and suggest that sex differences in peripheral nerves is a topic worthy of further study.
Collapse
Affiliation(s)
- Pamela A. McCombe
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Todd A. Hardy
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
- Brain & Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert J. Nona
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Judith M. Greer
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| |
Collapse
|
4
|
Querol LA, Hartung HP, Lewis RA, van Doorn PA, Hammond TR, Atassi N, Alonso-Alonso M, Dalakas MC. The Role of the Complement System in Chronic Inflammatory Demyelinating Polyneuropathy: Implications for Complement-Targeted Therapies. Neurotherapeutics 2022; 19:864-873. [PMID: 35378684 PMCID: PMC9294101 DOI: 10.1007/s13311-022-01221-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 01/01/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is the most common, heterogeneous, immune-mediated neuropathy, characterized by predominant demyelination of motor and sensory nerves. CIDP follows a relapsing-remitting or a progressive course and causes substantial disability. The pathogenesis of CIDP involves a complex interplay of multiple aberrant immune responses, creating a pro-inflammatory environment, subsequently inflicting damage on the myelin sheath. Though the exact triggers are unclear, diverse immune mechanisms encompassing cellular and humoral pathways are implicated. The complement system appears to play a role in promoting macrophage-mediated demyelination. Complement deposition in sural nerve biopsies, as well as signs of increased complement activation in serum and CSF of patients with CIDP, suggest complement involvement in CIDP pathogenesis. Here, we present a comprehensive overview of the preclinical and clinical evidence supporting the potential role of the complement system in CIDP. This understanding furnishes a strong rationale for targeting the complement system to develop new therapies that could serve the unmet needs of patients affected by CIDP, particularly in those refractory to standard therapies.
Collapse
Affiliation(s)
- Luis A Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | | | | | | | - Nazem Atassi
- Sanofi, Neurology Clinical Development, Cambridge, MA, USA
| | | | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Neuroimmunology National and Kapodistrian University of Athens Medical School, Athens, Greece.
| |
Collapse
|
5
|
Principles and Guidelines of Immunotherapy in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
6
|
Urbain F, Labeyrie C, Castilla-Llorente C, Cintas P, Puma A, Maubeuge N, Puyade M, Farge D. [Autologous hematopoietic stem cell transplantation for chronic inflammatory demyelinating polyneuropathy]. Rev Med Interne 2021; 42:639-649. [PMID: 33773849 DOI: 10.1016/j.revmed.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/02/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a dysimmune neuropathy with sensory and/or motor symptoms due to destruction of the myelin sheat secondary to an auto-immune attack. A quarter to a third of patients do not respond to immunomodulatory first line recommended therapies. No second line treatment has shown its effectiveness with a sufficient level of evidence. Autologous hematopoietic stem cell transplantation (AHSCT) is a promising therapy for autoimmune disease, especially for CIDP in recent works. We present in this article an update on the diagnosis of CIDP, its conventional treatments as well as the results of AHSCT in this indication, which was the subject of French recommendations under the aegis of the SFGMTC and neuromuscular disease french faculty (FILNEMUS) as a third line therapy after failure of two first-line and one second-line treatments.
Collapse
Affiliation(s)
- F Urbain
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, service de medecine interne, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France.
| | - C Labeyrie
- Assistance Publique-Hôpitaux de Paris, centre de reference maladies rares neuropathies amyloïdes familiales et autres neuropathies peripheriques rares, service de neurologie, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - C Castilla-Llorente
- Institut Gustave-Roussy, service d'hématologie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - P Cintas
- Explorations neurophysiologiques, centre SLA, centre de référence de pathologie neuromusculaire, CHU Toulouse, hôpital Pierre-Paul-Riquet, 31059 Toulouse Cedex, France
| | - A Puma
- Maladies du systeme nerveux peripherique et du muscle, Centre SLA, hôpital Pasteur 2-Zone C, CS 51069, 06001 Nice cedex 1, France
| | - N Maubeuge
- CHU de Poitiers, service de neurologie, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - M Puyade
- CHU de Poitiers, service de médecine interne et maladies infectieuses, 2, rue de la Milétrie, 86021 Poitiers cedex, France; CHU de Poitiers, CIC-1402, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - D Farge
- Unité de médecine interne, maladies auto-immunes et pathologie vasculaire UF04, Centre de référence des maladies auto-immunes systémiques rares d'Île-de-France MATHEC Hôpital Saint-Louis, UF04, Filière 'FAI2R', 1, avenue Claude-Vellefaux, 75475 Paris, France; Université de Paris, EA 3518, Paris, France; Département de Médecine, Université McGill, Montreal, QC, Canada
| |
Collapse
|
7
|
Hagen KM, Ousman SS. The immune response and aging in chronic inflammatory demyelinating polyradiculoneuropathy. J Neuroinflammation 2021; 18:78. [PMID: 33752693 PMCID: PMC7983397 DOI: 10.1186/s12974-021-02113-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/16/2021] [Indexed: 12/26/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consists of various autoimmune subtypes in which the peripheral nervous system (PNS) is attacked. CIDP can follow a relapsing-remitting or progressive course where the resultant demyelination caused by immune cells (e.g., T cells, macrophages) and antibodies can lead to disability in patients. Importantly, the age of CIDP patients has a role in their symptomology and specific variants have been associated with differing ages of onset. Furthermore, older patients have a decreased frequency of functional recovery after CIDP insult. This may be related to perturbations in immune cell populations that could exacerbate the disease with increasing age. In the present review, the immune profile of typical CIDP will be discussed followed by inferences into the potential role of relevant aging immune cell populations. Atypical variants will also be briefly reviewed followed by an examination of the available studies on the immunology underlying them.
Collapse
Affiliation(s)
- Kathleen M Hagen
- Department of Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - Shalina S Ousman
- Departments of Clinical Neurosciences and Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada.
| |
Collapse
|
8
|
Koike H, Katsuno M. Pathophysiology of Chronic Inflammatory Demyelinating Polyneuropathy: Insights into Classification and Therapeutic Strategy. Neurol Ther 2020; 9:213-227. [PMID: 32410146 PMCID: PMC7606443 DOI: 10.1007/s40120-020-00190-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Indexed: 01/11/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is classically defined as polyneuropathy with symmetric involvement of the proximal and distal portions of the limbs. In addition to this "typical CIDP", the currently prevailing diagnostic criteria proposed by the European Federation of Neurological Societies and Peripheral Nerve Society (EFNS/PNS) define "atypical CIDP" as encompassing the multifocal acquired demyelinating sensory and motor (MADSAM), distal acquired demyelinating symmetric (DADS), pure sensory, pure motor, and focal subtypes. Although macrophage-induced demyelination is considered pivotal to the pathogenesis of CIDP, recent studies have indicated the presence of distinctive mechanisms initiated by autoantibodies against paranodal junction proteins, such as neurofascin 155 and contactin 1. These findings led to the emergence of the concept of nodopathy or paranodopathy. Patients with these antibodies tend to show clinical features compatible with typical CIDP or DADS, particularly the latter. In contrast, classical macrophage-induced demyelination is commonly found in some patients in each major subtype, including the typical CIDP, DADS, MADSAM, and pure sensory subtypes. Differences in the distribution of lesions and the repair processes underlying demyelination by Schwann cells may determine the differences among subtypes. In particular, the preferential involvement of proximal and distal nerve segments has been suggested to occur in typical CIDP, whereas the involvement of the middle nerve segments is conspicuous in MADSAM. These findings suggest that humoral rather than cellular immunity predominates in the former because nerve roots and neuromuscular junctions lack blood-nerve barriers. Treatment for CIDP consists of intravenous immunoglobulin (IVIg) therapy, steroids, and plasma exchange, either alone or in combination. However, patients with anti-neurofascin 155 and contactin 1 antibodies are refractory to IVIg. It has been suggested that rituximab, a monoclonal antibody to CD20, could have efficacy in these patients. Further studies are needed to validate the CIDP subtypes defined by the EFNS/PNS from the viewpoint of pathogenesis and establish therapeutic strategies based on the pathophysiologies specific to each subtype.
Collapse
Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
9
|
Rodríguez Y, Vatti N, Ramírez-Santana C, Chang C, Mancera-Páez O, Gershwin ME, Anaya JM. Chronic inflammatory demyelinating polyneuropathy as an autoimmune disease. J Autoimmun 2019; 102:8-37. [DOI: 10.1016/j.jaut.2019.04.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
|
10
|
Kamil K, Yazid MD, Idrus RBH, Das S, Kumar J. Peripheral Demyelinating Diseases: From Biology to Translational Medicine. Front Neurol 2019; 10:87. [PMID: 30941082 PMCID: PMC6433847 DOI: 10.3389/fneur.2019.00087] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/22/2019] [Indexed: 12/30/2022] Open
Abstract
Demyelinating diseases represent a spectrum of disorders that impose significant burden on global economy and society. Generally, the prognosis of these diseases is poor and there is no available cure. In recent decades, research has shed some light on the biology and physiology of Schwann cells and its neuroprotective effects in the peripheral nervous system (PNS). Insults to the PNS by various infectious agents, genetic predisposition and immune-related mechanisms jeopardize Schwann cell functions and cause demyelination. To date, there are no effective and reliable biomarkers for PNS-related diseases. Here, we aim to review the following: pathogenesis of various types of peripheral demyelinating diseases such as Guillain-Barre syndrome, Chronic Inflammatory Demyelinating Polyradiculoneuropathy, Anti-Myelin Associated Glycoprotein Neuropathy, POEMS syndrome, and Charcot-Marie-Tooth disease; emerging novel biomarkers for peripheral demyelinating diseases, and Schwann cell associated markers for demyelination.
Collapse
Affiliation(s)
- Khidhir Kamil
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Dain Yazid
- Tissue Engineering Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Ruszymah Bt Hj Idrus
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Srijit Das
- Department of Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Jaya Kumar
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| |
Collapse
|
11
|
Moritz CP, Tholance Y, Rosier C, Reynaud-Federspiel E, Svahn J, Camdessanché JP, Antoine JC. Completing the Immunological Fingerprint by Refractory Proteins: Autoantibody Screening via an Improved Immunoblotting Technique. Proteomics Clin Appl 2019; 13:e1800157. [PMID: 30768763 DOI: 10.1002/prca.201800157] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/30/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Identifying autoantigens of serological autoantibodies requires expensive methods, such as protein microarrays or IP+MS. Thus, sera are commonly pre-screened for interesting immunopatterns via immunocytochemistry/immunohistochemistry. However, distinguishing immunopatterns can be difficult and intracellular antigens are less accessible. Therefore, a simple and cheap immunoblot screening able to distinguish immunopatterns and to detect refractory proteins is presented. EXPERIMENTAL DESIGN Five steps of immunoblotting-based autoantigen screening are revised: (1) choice of protein source, (2) protein extraction, (3) protein separation, (4) protein transfer, (5) antigen detection. Thereafter, 52 patients' sera with chronic inflammatory demyelinating polyneuropathy (CIDP) and 45 controls were screened. RESULTS The protein source impacts the detected antigen set. Steps 2-4 can be adapted for refractory proteins. Furthermore, longitudinal cutting of protein lanes saves ≥75% of time and material and allows for exact comparison of band patterns. As the latter are individually specific and temporarily constant, we call them "immunological fingerprints". In a proof-of-principle, a 155 kDa immunoband was detected with two anti-neurofascin-155-positive CIDP sera and two further immunobands (120/220 kDa) specific to a subgroup of 3-6 of 52 CIDP patients. CONCLUSIONS AND CLINICAL RELEVANCE Adapted immunoblotting is a cheap and simple method for accurate serum screening including refractory and intracellular antigens.
Collapse
Affiliation(s)
- Christian P Moritz
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Yannick Tholance
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Biochemistry Laboratory, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Carole Rosier
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Evelyne Reynaud-Federspiel
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Juliette Svahn
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Jean-Philippe Camdessanché
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Jean-Christophe Antoine
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| |
Collapse
|
12
|
Koike H, Nishi R, Ikeda S, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Ultrastructural mechanisms of macrophage-induced demyelination in CIDP. Neurology 2018; 91:1051-1060. [PMID: 30429275 DOI: 10.1212/wnl.0000000000006625] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/18/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a form of chronic neuropathy that is presumably caused by heterogeneous immune-mediated processes. Recent advances in the search for autoantibodies against components expressed at nodal regions, such as the nodes of Ranvier and paranodes, have substantially contributed to clarifying the pathogenesis of CIDP in a subpopulation of patients. In particular, immunoglobulin G4 (IgG4) antibodies to paranodal junction proteins, including neurofascin-155 and contactin-1, have attracted the attention of researchers. Paranodal dissection resulting from the attachment of IgG4 at paranodal junctions and the absence of macrophage-induced demyelination are characteristic pathologic features in patients who have these antibodies. By contrast, the mechanisms of neuropathy in cases with classical macrophage-induced demyelination remain unclear despite the long-standing recognition of this process in CIDP. In addition to complement-dependent damage provoked by autoantibodies, recent studies have shed light on antibody-dependent phagocytosis by macrophages without participation of complements. However, a direct association between specific autoantibodies and macrophage-induced demyelination has not been reported. Electron microscopic examination of longitudinal sections of sural nerve biopsy specimens suggested that macrophages recognize specific sites of myelinated fibers as the initial target of demyelination. The site that macrophages select to initiate myelin breakdown is located around the nodal regions in some patients and internode in others. Hence, it seems that the components that distinguish between the nodal regions and internode play a pivotal role in the behavior of macrophages that initiate phagocytosis of myelin. Further studies are needed to elucidate the mechanisms underlying macrophage-induced demyelination from this perspective.
Collapse
Affiliation(s)
- Haruki Koike
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan.
| | - Ryoji Nishi
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Shohei Ikeda
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Yuichi Kawagashira
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| |
Collapse
|
13
|
Roggenbuck JJ, Boucraut J, Delmont E, Conrad K, Roggenbuck D. Diagnostic insights into chronic-inflammatory demyelinating polyneuropathies. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:337. [PMID: 30306076 DOI: 10.21037/atm.2018.07.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare immune-mediated neuropathy with demyelination of nerve fibers as leading morphological feature. The course of disease can be chronic progressive or remitting relapsing. Whereas for acute immune-mediated neuropathies several serological markers have been identified and used successfully in clinical routine, the serological diagnosis of chronic variants such as CIDP has not yet been evolved satisfactory. The typical CIDP and its various atypical variants are characterized by a certain diversity of clinical phenotype and response to treatment. Thus, diagnostic markers could aid in the differential diagnosis of CIDP variants and stratification of patients for a better treatment response. Most patients respond well to a causal therapy including steroids, intravenous immunoglobulins and plasmapheresis. Apart from electrophysiological and morphological markers, several autoantibodies have been reported as candidate markers for CIDP, including antibodies against glycolipids or paranodal/nodal molecules. The present review provides a summary of the progress in autoantibody testing in CIDP and its possible implication on the stratification of the CIDP variants and treatment response.
Collapse
Affiliation(s)
| | - Joseph Boucraut
- Institut de Neurosciences de la Timone, Medicine Faculty, Aix Marseille University, Marseille, France.,Immunology laboratory, Conception Hospital, AP-HM, Marseille, France
| | - Emilien Delmont
- Referral Center for Neuromuscular Diseases and ALS, La Timone Hospital, AP-HM, Marseille, France
| | - Karsten Conrad
- Institute of Immunology, Technical University Dresden, Dresden, Germany
| | - Dirk Roggenbuck
- GA Generic Assays GmbH, Dahlewitz/Berlin, Germany.,Institute of Biotechnology, Faculty Environment and Natural Sciences, Brandenburg University of Technology, Senftenberg, Germany
| |
Collapse
|
14
|
Fehmi J, Scherer SS, Willison HJ, Rinaldi S. Nodes, paranodes and neuropathies. J Neurol Neurosurg Psychiatry 2018; 89:61-71. [PMID: 28819062 DOI: 10.1136/jnnp-2016-315480] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/13/2022]
Abstract
This review summarises recent evidence supporting the involvement of the specialised nodal and perinodal domains (the paranode and juxtaparanode) of myelinated axons in the pathology of acquired, inflammatory, peripheral neuropathies.The identification of new target antigens in the inflammatory neuropathies heralds a revolution in diagnosis, and has already begun to inform increasingly targeted and individualised therapies. Rapid progress in our basic understanding of the highly specialised nodal regions of peripheral nerves serves to strengthen the links between their unique microstructural identities, functions and pathologies. In this context, the detection of autoantibodies directed against nodal and perinodal targets is likely to be of increasing clinical importance. Antiganglioside antibodies have long been used in clinical practice as diagnostic serum biomarkers, and associate with specific clinical variants but not to the common forms of either acute or chronic demyelinating autoimmune neuropathy. It is now apparent that antibodies directed against several region-specific cell adhesion molecules, including neurofascin, contactin and contactin-associated protein, can be linked to phenotypically distinct peripheral neuropathies. Importantly, the immunological characteristics of these antibodies facilitate the prediction of treatment responsiveness.
Collapse
Affiliation(s)
- Janev Fehmi
- Department of Neurology, Southmead Hospital, Bristol, UK
| | - Steven S Scherer
- Department of Neurology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hugh J Willison
- Department of Neuroimmunology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Simon Rinaldi
- Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
15
|
Antibodies against peripheral nerve antigens in chronic inflammatory demyelinating polyradiculoneuropathy. Sci Rep 2017; 7:14411. [PMID: 29089585 PMCID: PMC5663697 DOI: 10.1038/s41598-017-14853-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/17/2017] [Indexed: 01/01/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a heterogeneous disease in which diverse autoantibodies have been described but systematic screening has never been performed. Detection of CIDP-specific antibodies may be clinically useful. We developed a screening protocol to uncover novel reactivities in CIDP. Sixty-five CIDP patients and 28 controls were included in our study. Three patients (4.6%) had antibodies against neurofascin 155, four (6.2%) against contactin-1 and one (1.5%) against the contactin-1/contactin-associated protein-1 complex. Eleven (18.6%) patients showed anti-ganglioside antibodies, and one (1.6%) antibodies against peripheral myelin protein 2. No antibodies against myelin protein zero, contactin-2/contactin-associated protein-2 complex, neuronal cell adhesion molecule, gliomedin or the voltage-gated sodium channel were detected. In IgG experiments, three patients (5.3%) showed a weak reactivity against motor neurons; 14 (24.6%) reacted against DRG neurons, four of them strongly (7.0%), and seven (12.3%) reacted against Schwann cells, three of them strongly (5.3%). In IgM experiments, six patients (10.7%) reacted against DRG neurons, while three (5.4%) reacted against Schwann cells. However, results were not statistically significant when compared to controls. Immunoprecipitation experiments identified CD9 and L1CAM as potential antigens, but reactivity could not be confirmed with cell-based assays. In summary, we describe a diverse autoantibody repertoire in CIDP patients, reinforcing the hypothesis of CIDP’s pathophysiological heterogeneity.
Collapse
|
16
|
Fujisawa M, Sano Y, Omoto M, Ogasawara JI, Koga M, Takashima H, Kanda T. Charcot-Marie-Tooth disease type 2 caused by homozygous MME gene mutation superimposed by chronic inflammatory demyelinating polyneuropathy. Rinsho Shinkeigaku 2017; 57:515-520. [PMID: 28855494 DOI: 10.5692/clinicalneurol.cn-001036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 59-year-old Japanese male who developed gradually worsening weakness and numbness of distal four extremities since age 50. His parents were first cousins, and blood and cerebral spinal examinations were unremarkable. Homozygous mutation of MME gene was detected and thus he was diagnosed as autosomal-recessive Charcot-Marie-Tooth disease 2T (AR-CMT2T); however, electrophysiological examinations revealed scattered demyelinative changes including elongated terminal latency in several peripheral nerve trunks. Sural nerve biopsy showed endoneurial edema and a lot of thinly myelinated nerve fibers with uneven distribution of remnant myelinated fibers within and between fascicles. Immunoglobulin treatment was initiated considering the possibility of superimposed inflammation and demyelination, and immediate clinical as well as electrophysiological improvements were noted. Our findings indicate that AR-CMT2T caused by MME mutation predisposes to a superimposed inflammatory demyelinating neuropathy. This is the first report which documented the co-existence of CMT2 and chronic inflammatory demyelinating polyneuropathy (CIDP); however, in the peripheral nervous system, neprilysin, a product of MME gene, is more abundant in myelin sheath than in axonal component. The fragility of myelin sheath due to mutated neprilysin may trigger the detrimental immune response against peripheral myelin in this patient.
Collapse
Affiliation(s)
- Miwako Fujisawa
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science.,Department of Neurology, Yamaguchi Prefectural Grand Medical Center
| | - Yasuteru Sano
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science
| | - Masatoshi Omoto
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science
| | - Jyun-Ichi Ogasawara
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medical Science
| |
Collapse
|
17
|
Autoantibodies in chronic inflammatory neuropathies: diagnostic and therapeutic implications. Nat Rev Neurol 2017; 13:533-547. [PMID: 28708133 DOI: 10.1038/nrneurol.2017.84] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The chronic inflammatory neuropathies (CINs) are rare, very disabling autoimmune disorders that generally respond well to immune therapies such as intravenous immunoglobulin (IVIg). The most common forms of CIN are chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multifocal motor neuropathy, and polyneuropathy associated with monoclonal gammopathy of unknown significance. The field of CIN has undergone a major advance with the identification of IgG4 autoantibodies directed against paranodal proteins in patients with CIDP. Although these autoantibodies are only found in a small subset of patients with CIDP, they can be used to guide therapeutic decision-making, as these patients have a poor response to IVIg. These observations provide proof of concept that identifying the target antigens in tissue-specific antibody-mediated autoimmune diseases is important, not only to understand their underlying pathogenic mechanisms, but also to correctly diagnose and treat affected patients. This state-of-the-art Review focuses on the role of autoantibodies against nodes of Ranvier in CIDP, a clinically relevant emerging field of research. The role of autoantibodies in other immune-mediated neuropathies, including other forms of CIN, primary autoimmune neuropathies, neoplasms, and systemic diseases that resemble CIN, are also discussed.
Collapse
|
18
|
Staudt M, Diederich JM, Meisel C, Meisel A, Klehmet J. Differences in peripheral myelin antigen-specific T cell responses and T memory subsets in atypical versus typical CIDP. BMC Neurol 2017; 17:81. [PMID: 28446142 PMCID: PMC5406908 DOI: 10.1186/s12883-017-0860-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/19/2017] [Indexed: 12/18/2022] Open
Abstract
Background Chronic inflammatory demyelinating polyneuropathy (CIDP) is presented by a large heterogeneity of clinical phenotypes. Around 50% of patients suffer from typical CIDP and show better therapy response than atypical variants. The goal of our study was to search for cellular immunological differences in typical versus atypical CIDP in comparison to controls. Methods We evaluated 26 (9 typical, 17 atypical) patients with mainly active-unstable CIDP using clinical and immunological examinations (enzyme-linked immunospot assay ELISPOT, fluorescence-activated cell sorting FACS) in comparison to 28 healthy, age-matched controls (HC). Typical or atypical CIDP measurements were compared with HC using Kruskal-Wallis test. Results Atypical CIDP patients showed increased frequencies of T cell subsets, especially CD4+ effector memory T cells (TEM) and CD4+ central memory T cells (TCM) as well as a tendency of higher T cell responses against the peripheral myelin antigens of PMP-22, P2, P0 and MBP peptides compared to typical CIDP. Searching for novel auto-antigens, we found that T cell responses against P0 180-199 as well as MBP 82-100 were significantly elevated in atypical CIDP patients vs. HC. Conclusions Our results indicate differences in underlying T cell responses between atypical and typical CIDP characterized by a higher peripheral myelin antigen-specific T cell responses as well as a specific altered CD4+ memory compartment in atypical CIDP. Larger multi-center studies study are warranted in order to characterize T cell auto-reactivity in atypical CIDP subgroups in order to establish immunological markers as a diagnostic tool.
Collapse
Affiliation(s)
- M Staudt
- Department of Neurology, Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - J M Diederich
- Department of Neurology, Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - C Meisel
- Department of Clinical Immunology, Charité University Medicine, Charitéplatz 1, Berlin, Germany
| | - A Meisel
- Department of Neurology, Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - J Klehmet
- Department of Neurology, Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany.
| |
Collapse
|
19
|
Léger JM, Haghi Ashtiani B, Guimaraes-Costa R. Investigated and emerging treatments for chronic inflammatory demyelinating polyradiculoneuropathy. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1285225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
20
|
Itaya K, Inoue M, Iizuka N, Shimizu Y, Yuki N, Ichikawa H. A case of a 17-year-old male with neurofascin-155 antibody-positive chronic inflammatory demyelinating polyradiculoneuropathy presenting with tremor and ataxia. Rinsho Shinkeigaku 2016; 56:633-6. [PMID: 27580761 DOI: 10.5692/clinicalneurol.cn-000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 17-year-old male with no medical history noticed weakness of his limbs with imbalance and subsequent finger tremors. Physical examination revealed features of polyneuropathy, including diffuse weakness, distal symmetrical numbness with impaired deep sensation and areflexia in all limbs. Postural tremor was present in fingers. Ataxia was apparent in both lower limbs, causing a wide-based gait with a positive Romberg sign. Cerebrospinal fluid contained elevated total protein without pleocytosis. A nerve conduction study disclosed demyelinating features with prolonged terminal latencies, slow velocities with delayed F-wave latencies, and prominent temporal dispersion. These findings led to diagnosis of typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with notable feature of postural finger tremor and ataxia of unknown cause. These atypical features prompted us to examine neurofascin-155 (NF155) antibodies, which were positive. No significant improvement occurred after initial administration of intravenous immunoglobulin and subsequent plasma exchange. However, corticosteroids with intravenous pulse therapy followed by oral prednisolone significantly improved the symptoms. Patients with CIDP with anti-NF155 antibodies may have similar clinical features and constitute a CIDP subgroup. In such patients, corticosteroids may be more effective than intravenous immunoglobulin. Further studies are needed to define the features of this subgroup and determine effective therapy for CIDP.
Collapse
Affiliation(s)
- Kazuhiro Itaya
- Department of Neurology, Showa University Fujigaoka Hospital
| | | | | | | | | | | |
Collapse
|
21
|
Regarding the past, what is the trial you have always been dreaming of in CIDP? Rev Neurol (Paris) 2016; 172:620-626. [PMID: 27638135 DOI: 10.1016/j.neurol.2016.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/29/2016] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy is an orphan disease of poorly understood cause. While first line treatments with corticosteroids, intravenous immunoglobulin and plasma exchange have at least short-term efficacy, no trial has shown that immunosuppressants work. In our dream, we will take advantage of the recently improved EU regulations to launch a Europe wide trial which will investigate the cause of the disease. It will compare three parallel groups, the anti-B cell agent rituximab, the anti-T cell agent abatacept and usual care. The trial will not be blinded and the design will be very simple. The primary outcome measure will be improvement from baseline of the overall neuropathy limitations scale (ONLS) score by 1 or more grades at 12 weeks without increase in concomitant corticosteroids or IVIg or use of plasma exchange. There will be an option to substitute improvement in the Rasch-built overall disability scale depending on future experience with that scale as the primary outcome measure. The trial will require 3 groups of 60 participants to detect an increase from 20% in the usual care group to 30% with one of the other agents with a power of 90% and P-value of 5%. It will be larger than any trial of an immunosuppressant agent so far performed in CIDP. However, recruitment will be easier because inclusion criteria will be broad and allow randomisation of any patient in whom their neurologist wishes to introduce an immunosuppressant. Avoidance of blinding and use of simple monitoring with facetime will simplify running the trial and reduce expense. The trial will follow participants and measure outcomes at 12 months. Other outcomes will consist only of grip strength, time to walk 10 m and Euroqol, the last allowing us to estimate the cost per QALY of rituximab or abatacept. Even including central analysis of key biomarkers, the trial will only cost 3 million euros, a fraction of the cost of the usual phase III pharmaceutical company trial.
Collapse
|
22
|
Richard A, Corvol JC, Debs R, Reach P, Tahiri K, Carpentier W, Gueguen J, Guillemot V, Labeyrie C, Adams D, Viala K, Cohen Aubart F. Transcriptome Analysis of Peripheral Blood in Chronic Inflammatory Demyelinating Polyradiculoneuropathy Patients Identifies TNFR1 and TLR Pathways in the IVIg Response. Medicine (Baltimore) 2016; 95:e3370. [PMID: 27175635 PMCID: PMC4902477 DOI: 10.1097/md.0000000000003370] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We have studied the response to intravenous immunoglobulins (IVIg) by a transcriptomic approach in 11 chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients (CIDP duration = 6 [0.83-6.5] years). RNA was extracted from cells in whole blood collected before and 3 weeks after IVIg treatment, and hybridized on Illumina chips. After RNA quality controls, gene expression was analyzed using statistical tests fitted for microarrays (R software, limma package), and a pathway analysis was performed using DAVID software. We identified 52 genes with expression that varied significantly after IVIg (fold change [FC] > 1.2, P < 0.001, false discovery rate [FDR] <0.05). Among these 52 genes, 7 were related to immunity, 3 were related to the tumor necrosis factor (TNF)-α receptor 1 (TNFR1) pathway (inhibitor of caspase-activated DNase (ICAD): FC = 1.8, P = 1.7E-7, FDR = 0.004; p21 protein-activated kinase 2 [PAK2]: FC = 1.66, P = 2.6E-5, FDR = 0.03; TNF-α-induced protein 8-like protein 1 [TNFAIP8L1]: P = 1.00E-05, FDR = 0.026), and 2 were related to Toll-like receptors (TLRs), especially TLRs 7 and 9, and were implicated in autoimmunity. These genes were UNC93B1 (FC = 1.6, P = 2E-5, FDR = 0.03), which transports TLRs 7 and 9 to the endolysosomes, and RNF216 (FC = 1.5, P = 1E-05, FDR = 0.03), which promotes TLR 9 degradation. Pathway analysis showed that the TNFR1 pathway was significantly lessened by IVIg (enrichment score = 24, Fischer exact test = 0.003). TNF-α gene expression was higher in responder patients than in nonresponders; however, it decreased after IVIg in responders (P = 0.04), but remained stable in nonresponders. Our data suggest the actions of IVIg on the TNFR1 pathway and an original mechanism involving innate immunity through TLRs in CIDP pathophysiology and the response to IVIg. We conclude that responder patients have stronger inflammatory activity that is lessened by IVIg.
Collapse
Affiliation(s)
- Alexandra Richard
- From the Sorbonne Universités (AR, J-CC, KT), UPMC Univ Paris 06, INSERM UMRS_1127, CIC_1422, CNRS UMR_7225, AP-HP, and ICM, Hôpital Pitié-Salpêtrière, Département des maladies du système nerveux; Hôpital Pitié Salpêtrière (RD, PR, KV), Département de Neurophysiologie Clinique; Plateforme Post-génomique P3S (WC), UPMC, Site Pitié Salpêtrière; IHU-A-ICM Bioinformatics/Biostatistics Core Facility (JG, VG), Paris; Hôpital de Bicêtre (CL, DA), Centre de Référence des Neuropathies Amyloïdes et autres Neuropathies Périphériques Rares, Le Kremlin-Bicêtre; and AP-HP, Hôpital Pitié Salpêtrière, Service de Médecine Interne, Institut E3M, Centre National de Référence Maladies auto-immunes Systémiques Rares, et Université Paris VI Pierre et Marie Curie, Sorbonnes Université, Paris, France (FCA)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
Peripheral neuropathies have diverse acquired and inherited causes. The autoimmune neuropathies represent an important category where treatment is often available. There are overlapping signs and symptoms between autoimmune neuropathies and other forms. Making a diagnosis can be challenging and first assisted by electrophysiologic and sometimes pathologic sampling, with autoimmune biomarkers providing increased assistance. Here we provide a review of the autoimmune and inflammatory neuropathies, their available biomarkers, and approaches to treatment. Also discussed is new evidence to support a mechanism of autoimmune pain.
Collapse
|
24
|
Abstract
UNLABELLED Chronic inflammatory demyelinating polyradiculoneuropathy is a chronic progressive or relapsing and remitting disease with a prevalence of up to 8.9 per 100,000. METHODS This review discusses possible mechanisms, none of which are proven, and describes the evidence for its treatment. RESULTS Cochrane Reviews provide evidence that corticosteroids, intravenous immunoglobulin, and plasma exchange are effective short-term treatments. Attempts to confirm the efficacy of other immunosuppressant agents have not been successful, although they are often used in people whose disease is resistant to the first-line treatments. CONCLUSIONS More and better trials are needed.
Collapse
Affiliation(s)
- Richard Hughes
- MRC Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, PO Box 114, Queen Square, London, WC1N 3BG, UK,
| |
Collapse
|
25
|
Inflammatory neuropathies: pathology, molecular markers and targets for specific therapeutic intervention. Acta Neuropathol 2015; 130:445-68. [PMID: 26264608 DOI: 10.1007/s00401-015-1466-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 08/01/2015] [Accepted: 08/02/2015] [Indexed: 12/21/2022]
Abstract
Inflammatory neuropathies encompass groups of heterogeneous disorders characterized by pathogenic immune-mediated hematogenous leukocyte infiltration of peripheral nerves, nerve roots or both, with resultant demyelination or axonal degeneration or both. Inflammatory neuropathies may be divided into three major disease categories: Guillain-Barré syndrome (particularly the acute inflammatory demyelinating polyradiculoneuropathy variant), chronic inflammatory demyelinating polyradiculoneuropathy and nonsystemic vasculitic neuropathy (or peripheral nerve vasculitis). Despite major advances in molecular biology, pathology and genetics, the pathogenesis of these disorders remains elusive. There is insufficient knowledge on the mechanisms of hematogenous leukocyte trafficking into the peripheral nervous system to guide the development of specific molecular therapies for immune-mediated inflammatory neuropathies compared to disorders such as psoriasis, inflammatory bowel disease, rheumatoid arthritis or multiple sclerosis. The recent isolation and characterization of human endoneurial endothelial cells that form the blood-nerve barrier provides an opportunity to elucidate leukocyte-endothelial cell interactions critical to the pathogenesis of inflammatory neuropathies at the interface between the systemic circulation and peripheral nerve endoneurium. This review discusses our current knowledge of the classic pathological features of inflammatory neuropathies, attempts at molecular classification and genetic determinants, the utilization of in vitro and in vivo animal models to determine pathogenic mechanisms at the interface between the systemic circulation and the peripheral nervous system relevant to these disorders and prospects for future potential molecular pathology biomarkers and targets for specific therapeutic intervention.
Collapse
|
26
|
Mathey EK, Park SB, Hughes RAC, Pollard JD, Armati PJ, Barnett MH, Taylor BV, Dyck PJB, Kiernan MC, Lin CSY. Chronic inflammatory demyelinating polyradiculoneuropathy: from pathology to phenotype. J Neurol Neurosurg Psychiatry 2015; 86:973-85. [PMID: 25677463 PMCID: PMC4552934 DOI: 10.1136/jnnp-2014-309697] [Citation(s) in RCA: 263] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/09/2014] [Accepted: 12/11/2014] [Indexed: 11/04/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory neuropathy, classically characterised by a slowly progressive onset and symmetrical, sensorimotor involvement. However, there are many phenotypic variants, suggesting that CIDP may not be a discrete disease entity but rather a spectrum of related conditions. While the abiding theory of CIDP pathogenesis is that cell-mediated and humoral mechanisms act together in an aberrant immune response to cause damage to peripheral nerves, the relative contributions of T cell and autoantibody responses remain largely undefined. In animal models of spontaneous inflammatory neuropathy, T cell responses to defined myelin antigens are responsible. In other human inflammatory neuropathies, there is evidence of antibody responses to Schwann cell, compact myelin or nodal antigens. In this review, the roles of the cellular and humoral immune systems in the pathogenesis of CIDP will be discussed. In time, it is anticipated that delineation of clinical phenotypes and the underlying disease mechanisms might help guide diagnostic and individualised treatment strategies for CIDP.
Collapse
Affiliation(s)
- Emily K Mathey
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Susanna B Park
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia Neuroscience Research Australia & Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - John D Pollard
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia J Armati
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Michael H Barnett
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce V Taylor
- Menzies Research Institute, University of Tasmania, Sydney, New South Wales, Australia
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew C Kiernan
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Cindy S-Y Lin
- Faculty of Medicine, Department of Physiology, Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Randwick, New South Wales, Australia
| |
Collapse
|
27
|
Mehndiratta MM, Hughes RAC, Pritchard J. Plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2015; 2015:CD003906. [PMID: 26305459 PMCID: PMC6734114 DOI: 10.1002/14651858.cd003906.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an uncommon progressive or relapsing paralysing disease caused by inflammation of the peripheral nerves. If the hypothesis that it is due to autoimmunity is correct, removal of autoantibodies in the blood by plasma exchange should be beneficial. OBJECTIVES To assess the effects of plasma exchange for treating CIDP. SEARCH METHODS On 30 June 2015, we searched the Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, and LILACS. We also scrutinised the bibliographies of the trials, contacted the trial authors and other disease experts, and searched trials registries for ongoing studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs in participants of any age comparing plasma exchange with sham treatment or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently selected the trials, extracted the data, and assessed risk of bias. Where possible the review authors combined data according to the methods of the Cochrane Neuromuscular Disease Review Group. MAIN RESULTS PRIMARY OUTCOME MEASURE one cross-over trial including 18 participants showed after four weeks, 2 (95% confidence interval (CI) 0.8 to 3.0) points more improvement on an 11-point disability scale with plasma exchange (10 exchanges over four weeks) than with sham exchange. Rapid deterioration after plasma exchange occurred in eight of 12 who had improved. SECONDARY OUTCOME MEASURES when we combined the results of this cross-over trial and a trial with 29 participants treated in a parallel-group design, there were 31 points (95% CI 16 to 45) more improvement on an impairment scale (maximum score 280) after plasma exchange (six exchanges over three weeks) than after sham exchange. There were significant improvements in both trials in an electrophysiological measure, the proximally evoked compound muscle action potential, after three or four weeks. Nonrandomised evidence indicates that plasma exchange induces adverse events in 3% to 17% of procedures. These events are sometimes serious. Both trials had a low risk of bias. A trial that showed no significant difference in the benefit between plasma exchange and intravenous immunoglobulin is included in the Cochrane review of intravenous immunoglobulin for this condition. AUTHORS' CONCLUSIONS Moderate- to high-quality evidence from two small trials shows that plasma exchange provides significant short-term improvement in disability, clinical impairment, and motor nerve conduction velocity in CIDP but rapid deterioration may occur afterwards. Adverse events related to difficulty with venous access, use of citrate, and haemodynamic changes are not uncommon. We need more research to identify agents that will prolong the beneficial action of plasma exchange.
Collapse
Affiliation(s)
- Man Mohan Mehndiratta
- Janakpuri Superspecialty HospitalDepartment of NeurologyC‐2/B, JanakpuriNew DelhiDelhiIndia110058
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Jane Pritchard
- Charing Cross HospitalNeuromuscular Unit 3 NorthFulham Palace RoadLondonUKW6 8RF
| | | |
Collapse
|
28
|
Blum S, Csurhes P, McCombe P. The frequencies of Killer immunoglobulin-like receptors and their HLA ligands in chronic inflammatory demyelinating polyradiculoneuropathy are similar to those in Guillian Barre syndrome but differ from those of controls, suggesting a role for NK cells in pathogenesis. J Neuroimmunol 2015. [PMID: 26198918 DOI: 10.1016/j.jneuroim.2015.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired inflammatory neuropathy, which has similar clinical and pathological features to Guillain-Barré Syndrome (GBS), but differs in time course. We investigated the frequency of genes encoding Killer immunoglobulin-like receptors and their HLA ligands in subjects with CIDP, in subjects with GBS and in healthy controls. There were no differences in KIR gene frequency among the 3 groups. The gene frequencies for HLA-B Bw4-I were significantly greater in CIDP than HC, but did not differ from GBS. The frequency of the combination of 3DL1/HLA-B Bw4I was greater in CIDP than HC, but did not differ from that of GBS. These data raise the possibility of NK cell function being an important factor in the pathogenesis of CIDP.
Collapse
Affiliation(s)
- Stefan Blum
- Royal Brisbane and Women's Hospital, Department of Neurology, Butterfield Street, Herston QLD 4029, Australia; University of Queensland, Centre for Clinical Research, Herston Campus, Herston, QLD 4029, Australia
| | - Peter Csurhes
- University of Queensland, Centre for Clinical Research, Herston Campus, Herston, QLD 4029, Australia
| | - Pamela McCombe
- Royal Brisbane and Women's Hospital, Department of Neurology, Butterfield Street, Herston QLD 4029, Australia; University of Queensland, Centre for Clinical Research, Herston Campus, Herston, QLD 4029, Australia
| |
Collapse
|
29
|
Beppu M, Sawai S, Satoh M, Mori M, Kazami T, Misawa S, Shibuya K, Ishibashi M, Sogawa K, Kado S, Kodera Y, Nomura F, Kuwabara S. Autoantibodies against vinculin in patients with chronic inflammatory demyelinating polyneuropathy. J Neuroimmunol 2015; 287:9-15. [PMID: 26439954 DOI: 10.1016/j.jneuroim.2015.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/19/2015] [Accepted: 07/24/2015] [Indexed: 11/30/2022]
Abstract
To identify the target molecules of chronic inflammatory demyelinating polyneuropathy (CIDP), we used proteomic-based approach in the extracted proteins from porcine cauda equina. Two of 31 CIDP patients had markedly elevated serum autoantibodies against vinculin, a cell adhesion protein. Both of the patients with anti-vinculin antibodies had similar clinical manifestation, which are compatible with those of "typical" CIDP. Immunocytochemistry showed that vinculin was stained at the myelin sheath of the sciatic nerves by serum samples. Our results suggest that vinculin is a possible immunological target molecule in a subpopulation of typical CIDP patients.
Collapse
Affiliation(s)
- Minako Beppu
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan; Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Setsu Sawai
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Mamoru Satoh
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Takahiro Kazami
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Sonoko Misawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Kazumoto Shibuya
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Masumi Ishibashi
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Kazuyuki Sogawa
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Sayaka Kado
- Chemical Analysis Center, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba 263-8522, Japan
| | - Yoshio Kodera
- Department of Physics, School of Science, Kitasato University, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Fumio Nomura
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| |
Collapse
|
30
|
Klehmet J, Goehler J, Ulm L, Kohler S, Meisel C, Meisel A, Harms H. Effective treatment with intravenous immunoglobulins reduces autoreactive T-cell response in patients with CIDP. J Neurol Neurosurg Psychiatry 2015; 86:686-91. [PMID: 25074566 DOI: 10.1136/jnnp-2014-307708] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 07/10/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate changes in autoreactive T-cell responses against PMP-22 and P2 antigen as well as a T-cell memory repertoire in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) induced by repeated intravenous immunoglobulin (IVIg) treatment. METHODS In an observational trial, we prepared cryopreserved human peripheral blood monocytes from blood from 34 patients with CIDP (18 treatment naïve and 16 maintenance IVIg treatment) and from 14 healthy controls (non-immune neuropathy and healthy control). Treatment response was defined by clinical evaluation. The autoantigen-specific T-cell response was analysed by enzyme linked immunosorbent spot (ELISPOT) assay before IVIg start (baseline) and at follow-up. The T-cell memory subsets were analysed by using flow cytometric analysis. RESULTS Myelin-derived P2-specific and PMP-22-specific IFN-γ producers were increased in IVIg responders compared with non-responders before treatment, which decreased by repeated IVIg infusion cycles. Treatment responders but not non-responders showed higher frequencies of CD4 T effector memory (TEM) and T central memory frequencies at baseline compared with maintenance IVIg treatment patients and controls. In addition, IVIg treatment was associated with a significant reduction in CD8 TEM at follow-up. CONCLUSIONS Our data demonstrate that immunomodulatory treatment with IVIgs on a long-term basis reduces the autoreactive T-cell response against PMP-22 and P2-antigens, which may be influenced by the altered maintenance of CD8 and CD4 effector/memory T-cell subsets towards a more anti-inflammatory immune status. Elevated PMP-22 and P2-specific T-cell responses may serve as predictors for treatment responsiveness to IVIgs warranting validation in larger studies.
Collapse
Affiliation(s)
- Juliane Klehmet
- Department of Neurology, University Hospital Charité, Berlin, Germany
| | - Jos Goehler
- Department of Neurology, University Hospital Charité, Berlin, Germany
| | - Lena Ulm
- Department of Neurology, University Hospital Charité, Berlin, Germany
| | - Siegfried Kohler
- Department of Neurology, University Hospital Charité, Berlin, Germany
| | - Christian Meisel
- Institute of Medical Immunology, Charité, Berlin Department of Immunology, Labor Berlin Charité
| | - Andreas Meisel
- Department of Neurology, University Hospital Charité, Berlin, Germany
| | - Hendrik Harms
- Department of Neurology, St. Josefs Krankenhaus Potsdam, Potsdam, Germany
| |
Collapse
|
31
|
Pathogenesis of immune-mediated neuropathies. Biochim Biophys Acta Mol Basis Dis 2015; 1852:658-66. [DOI: 10.1016/j.bbadis.2014.06.013] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/09/2014] [Indexed: 11/20/2022]
|
32
|
Berger M, Allen JA. Optimizing IgG therapy in chronic autoimmune neuropathies: a hypothesis driven approach. Muscle Nerve 2015; 51:315-26. [PMID: 25418426 PMCID: PMC4357394 DOI: 10.1002/mus.24526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
Prolonged intravenous immunoglobulin (IVIG) therapy is used for the chronic autoimmune neuropathies chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy, but the doses and treatment intervals are usually chosen empirically due to a paucity of data from dose-response studies. Recent studies of the electrophysiology and immunology of these diseases suggest that antibody-induced reversible dysfunction of nodes of Ranvier may play a role in conduction block and disability which responds to immunotherapy more rapidly than would be expected for demyelination or axonal damage per se. Clinical reports suggest that in some cases, the effects of each dose of IVIG may be transient, wearing-off before the next dose is due. These observations lead us to hypothesize that that therapeutic IgG acts by competing with pathologic autoantibodies and that individual patients may require different IgG levels for optimal therapeutic effects. Frequent IVIG dosing and weekly subcutaneous IgG have been tried as ways of continuously maintaining high serum IgG levels, resulting in stabilization of neuromuscular function in small case series. Frequent grip strength and disability measurements, performed by the patient at home and reported electronically, can be used to assess the extent and duration of responses to IgG doses. Individualization of IgG treatment regimens may optimize efficacy, minimize disability, and identify nonresponders.
Collapse
Affiliation(s)
- Melvin Berger
- CSL Behring, LLC., 1040 First Avenue, King of PrussiaPennsylvania, USA 19406
| | - Jeffrey A Allen
- University of MinnesotaMinneapolis, Minnesota, USA
- Northwestern UniversityChicago, Illinois, USA
| |
Collapse
|
33
|
Beppu M, Sawai S, Misawa S, Sogawa K, Mori M, Ishige T, Satoh M, Nomura F, Kuwabara S. Serum cytokine and chemokine profiles in patients with chronic inflammatory demyelinating polyneuropathy. J Neuroimmunol 2015; 279:7-10. [DOI: 10.1016/j.jneuroim.2014.12.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/14/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
|
34
|
Svahn J, Antoine JC, Camdessanché JP. Pathophysiology and biomarkers in chronic inflammatory demyelinating polyradiculoneuropathies. Rev Neurol (Paris) 2014; 170:808-17. [PMID: 25459126 DOI: 10.1016/j.neurol.2014.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired dysimmune disorder characterized by strong heterogeneity in terms of clinical manifestations, prognostic and response to treatment. To date, its pathophysiology and potential target antigens are not totally identified despite substantial progress in the understanding of the involved molecular mechanisms. Recent researches in the field have underlined the importance of cell-mediated immunity (lymphocytesT CD4+, CD8+ and macrophages), the breakdown of blood-nerve barrier, a failure of T-cell regulation, and the disruption of nodal and paranodal organization at the node of Ranvier. This last point is possibly mediated by autoantibodies towards axoglial adhesion molecules which may disrupt sodium and potassium voltage-gated channels clustering leading to a failure of saltatory conduction and the apparition of conduction blocks. The purpose of this article is to overview the main pathophysiologic mechanisms and biomarkers identified in CIDP.
Collapse
Affiliation(s)
- J Svahn
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Université Claude-Bernard Lyon 1, 69003 Lyon, France
| | - J-C Antoine
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Service de neurologie, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France; Centre référent maladies neuromusculaires rares Rhône-Alpes, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France
| | - J-P Camdessanché
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Service de neurologie, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France; Centre référent maladies neuromusculaires rares Rhône-Alpes, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France.
| |
Collapse
|
35
|
Nobile-Orazio E. Chronic inflammatory demyelinating polyradiculoneuropathy and variants: where we are and where we should go. J Peripher Nerv Syst 2014; 19:2-13. [PMID: 24612201 DOI: 10.1111/jns5.12053] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic and often disabling sensory motor neuropathy postulated as caused by an immune attack against peripheral nerve myelin. In addition to a classic sensory–motor polyneuropathy, other phenotypes of CIDP have been described including the Lewis- Sumner syndrome, distal acquired demyelinating symmetric (DADS) neuropathy, pure motor CIDP, pure sensory CIDP including chronic immune sensory polyradiculopathy (CISP), and focal CIDP. These phenotypes are currently considered to be variants of CIDP, even if the possibility that they represent different demyelinating neuropathies cannot be fully excluded considering differences in their response to therapy. Several data support the role of the immune system in the pathogenesis of CIDP even if the precise targets and actors (antibodies and lymphocytes) of this immune response remain uncertain. Recent studies have shown that the therapeutic response may differ in patients with peculiar clinical presentations supporting the hypothesis that different pathogenetic mechanisms may underlie the heterogeneity of CIDP. The majority of patients with CIDP show improvement after immune therapies including corticosteroids, plasma exchange, and high-dose intravenous immunoglobulin (IVIg). It remains unclear why none of the other immune therapies that were reported to be variably effective in other immune disorders proved to be effective also in CIDP.
Collapse
|
36
|
Peripheral nerve proteins as potential autoantigens in acute and chronic inflammatory demyelinating polyneuropathies. Autoimmun Rev 2014; 13:1070-8. [DOI: 10.1016/j.autrev.2014.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 06/27/2014] [Indexed: 01/06/2023]
|
37
|
Yan W, Nguyen T, Yuki N, Ji Q, Yiannikas C, Pollard JD, Mathey EK. Antibodies to neurofascin exacerbate adoptive transfer experimental autoimmune neuritis. J Neuroimmunol 2014; 277:13-7. [PMID: 25262157 DOI: 10.1016/j.jneuroim.2014.09.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 08/27/2014] [Accepted: 09/13/2014] [Indexed: 12/29/2022]
Abstract
Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy are autoimmune disorders of the peripheral nervous system in which autoantibodies are implicated in the disease pathogenesis. Recent work has focused on the nodal regions of the myelinated axon as potential autoantibody targets. Here we screened patient sera for autoantibodies to neurofascin and assessed the pathophysiological relevance of anti-neurofascin antibodies in vivo. Levels of anti-neurofascin antibodies were higher in sera from patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy when compared with those of controls. Anti-neurofascin antibodies exacerbated and prolonged adoptive transfer experimental autoimmune neuritis and caused conduction defects when injected intraneurally.
Collapse
Affiliation(s)
- Weixing Yan
- Neuroinflammation Group, Brain & Mind Research Institute, University of Sydney, Sydney, Australia
| | - Toan Nguyen
- Neuroinflammation Group, Brain & Mind Research Institute, University of Sydney, Sydney, Australia
| | - Nobuhiro Yuki
- Departments of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Qiuhong Ji
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Con Yiannikas
- Neuroinflammation Group, Brain & Mind Research Institute, University of Sydney, Sydney, Australia
| | - John D Pollard
- Neuroinflammation Group, Brain & Mind Research Institute, University of Sydney, Sydney, Australia
| | - Emily K Mathey
- Neuroinflammation Group, Brain & Mind Research Institute, University of Sydney, Sydney, Australia.
| |
Collapse
|
38
|
Guimarães-Costa R, Iancu Ferfoglia R, Viala K, Léger JM. Challenges in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy. Rev Neurol (Paris) 2014; 170:595-601. [PMID: 25200479 DOI: 10.1016/j.neurol.2014.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 06/19/2014] [Accepted: 06/24/2014] [Indexed: 11/28/2022]
Abstract
Chronic idiopathic demyelinating polyradiculoneuropathy (CIDP) is a rare disease, the most frequent one within the spectrum of the so-called "chronic immune-mediated neuropathies". Challenges in the treatment of CIDP firstly concern its diagnosis, which may be difficult, mainly for the atypical forms. Secondly, challenges encompass the choice of the first-line treatment, such as corticosteroids, intravenous immunoglobulins (IVIg), and plasma exchanges (PE) that have been proven as efficacious by several randomized controlled trials (RCT). Recent reports have focused on both different regimens of corticosteroids, and the occurrence of relapses following treatment with either corticosteroids or IVIg. These data may be helpful for the choice of the first-line treatment and may result in changing the guidelines for treatment of CIDP in clinical practice. The third and more difficult challenge is to manage long-term treatment for CIDP, since no immunomodulatory treatment has to date been proven as efficacious in this situation. Lastly, challenges in the treatment concern the choice of the best outcome measure for CIDP in RCT and clinical practice. The aim of this article is to overview the results of the more recently reported published trials for CIDP, and to give some insights for the current and future management of CIDP.
Collapse
Affiliation(s)
- R Guimarães-Costa
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - R Iancu Ferfoglia
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - K Viala
- Fédération de neurophysiologie clinique, institut hospitalo-universitaire de neurosciences, groupe hospitalier Pitié-Salpêtrière, université Pierre-et-Marie-Curie (Paris VI), 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - J-M Léger
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| |
Collapse
|
39
|
Park SB, Sung JY, Tani J, Kiernan MC, Lin CSY. Reply: biomarkers of 'acute-onset' chronic inflammatory demyelinating polyneuropathy. Brain 2014; 138:e336. [PMID: 25183715 DOI: 10.1093/brain/awu254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Susanna B Park
- 1 Neuroscience Research Australia and Prince of Wales Clinical School, University of New South Wales, Australia
| | - Jia-Ying Sung
- 2 Department of Neurology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jowy Tani
- 3 Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Matthew C Kiernan
- 4 Brain and Mind Research Institute and Central Clinical School, University of Sydney, Sydney, Australia
| | - Cindy S-Y Lin
- 5 School of Medical Sciences, University of New South Wales, Sydney, Australia
| |
Collapse
|
40
|
Vallat JM. Peripheral nervous system neuroimmunology seen by a neuro-pathologist. Rev Neurol (Paris) 2014; 170:564-9. [PMID: 25200480 DOI: 10.1016/j.neurol.2014.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/25/2014] [Indexed: 12/28/2022]
Abstract
In most dysimmune neuropathies, historically the microscopical lesions were described prior to immunological studies. The latter along with neuropathological studies have found some immune, albeit incomplete, explanations of the mechanisms of these lesions which we will describe in two main syndromes: the primitive auto-immune inflammatory peripheral polyneuropathies (GBS and CIDP) and polyneuropathies induced by a monoclonal dysglobulinemia. In some patients who have to be discussed case by case pathology (nerve biopsy) will confirm the diagnosis, may help to delineate the molecular anomalies and identify lesional mechanisms. We will review the high variability of nerve lesions which is characteristic of dysimmune neuropathies. Pathological studies confirm that both humoral and cellular immune reactions against Schwann cell and/or axonal antigens are implicated in primitive dysimmune neuropathies due to a dysfunction or failure of immune tolerance mechanisms. In case of a polyneuropathy associated to a monoclonal dysglobulinemia, pathological and immunological studies have shown that in many patients, the dysglobulinemia did harm the peripheral nerve; knowledge of the pathological lesions and their mechanisms is of major interest for orienting specific treatments.
Collapse
Affiliation(s)
- J-M Vallat
- Neurology Department, University hospital, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
| |
Collapse
|
41
|
Abraham PM, Quan SH, Dukala D, Soliven B. CD19 as a therapeutic target in a spontaneous autoimmune polyneuropathy. Clin Exp Immunol 2014; 175:181-91. [PMID: 24116957 DOI: 10.1111/cei.12215] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2013] [Indexed: 01/21/2023] Open
Abstract
Spontaneous autoimmune polyneuropathy (SAP) in B7-2 knock-out non-obese diabetic (NOD) mice is mediated by myelin protein zero (P0)-reactive T helper type 1 (Th1) cells. In this study, we investigated the role of B cells in SAP, focusing on CD19 as a potential therapeutic target. We found that P0-specific plasmablasts and B cells were increased in spleens of SAP mice compared to wild-type NOD mice. Depletion of B cells and plasmablasts with anti-CD19 monoclonal antibody (mAb) led to attenuation of disease severity when administered at 5 months of age. This was accompanied by decreased serum immunoglobulin (Ig)G and IgM levels, depletion of P0-specific plasmablasts and B cells, down-regulation/internalization of surface CD19 and increased frequency of CD4(+) regulatory T cells in spleens. We conclude that B cells are crucial to the pathogenesis of SAP, and that CD19 is a promising B cell target for the development of disease-modifying agents in autoimmune neuropathies.
Collapse
Affiliation(s)
- P M Abraham
- Department of Neurology, The University of Chicago, Chicago, IL, USA
| | | | | | | |
Collapse
|
42
|
Odaka M. Chronic inflammatory demyelinating polyneuropathy: a treatment protocol proposal. Expert Rev Neurother 2014; 6:365-79. [PMID: 16533141 DOI: 10.1586/14737175.6.3.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Guidelines for diagnostic criteria and treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) have been proposed by a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society, based on available evidence and expert consensus. These should prove practical for the clinical management of CIDP. Intravenous immunoglobulin followed by corticosteroids should be considered as the initial treatment, however no clear second drug of choice for patients who do not respond to the initial treatment is given. The author reports the long-term therapeutic efficacy of ciclosporin for patients with CIDP who did not show sustained improvement under steroid therapy. Ciclosporin should be tried for patients with intractable CIDP who require repeated intravenous immunoglobulin. An adequate initial dose of ciclosporin is 3 mg/kg/day, with plasma trough concentrations between 100 and 150 ng/ml. If patients respond to ciclosporin, remission can be maintained for 2 years, after which the dose can be slowly reduced over 1 year. Eventual withdrawal should be considered. This review proposes a treatment strategy that includes long-term maintenance therapy for CIDP based on published clinical trials and the author's clinical experience. Current concepts concerning the clinical spectrum of CIDP and diagnostic approaches are also considered.
Collapse
Affiliation(s)
- Masaaki Odaka
- Department of Neurology, Dokkyo University School of Medicine, Kitakobayashi 880, Mibu, Shimotsuga, Tochigi 321-0293, Japan.
| |
Collapse
|
43
|
Abstract
The peripheral nervous system (PNS) comprises the cranial nerves, the spinal nerves with their roots and rami, dorsal root ganglia neurons, the peripheral nerves, and peripheral components of the autonomic nervous system. Cell-mediated or antibody-mediated immune attack on the PNS results in distinct clinical syndromes, which are classified based on the tempo of illness, PNS component(s) involved, and the culprit antigen(s) identified. Insights into the pathogenesis of autoimmune neuropathy have been provided by ex vivo immunologic studies, biopsy materials, electrophysiologic studies, and experimental models. This review article summarizes earlier seminal observations and highlights the recent progress in our understanding of immunopathogenesis of autoimmune neuropathies based on data from animal models.
Collapse
Affiliation(s)
- Betty Soliven
- Address correspondence and reprint requests to Dr. Betty Soliven, Room S225, Department of Neurology MC2030, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637 or
| |
Collapse
|
44
|
Mathey EK, Pollard JD. Chronic inflammatory demyelinating polyneuropathy. J Neurol Sci 2013; 333:37-42. [DOI: 10.1016/j.jns.2012.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 10/14/2012] [Accepted: 10/22/2012] [Indexed: 12/12/2022]
|
45
|
Dalakas MC. Pathophysiology of autoimmune polyneuropathies. Presse Med 2013; 42:e181-92. [DOI: 10.1016/j.lpm.2013.01.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/14/2013] [Indexed: 11/16/2022] Open
|
46
|
Van den Bergh PY, Rajabally YA. Chronic inflammatory demyelinating polyradiculoneuropathy. Presse Med 2013; 42:e203-15. [DOI: 10.1016/j.lpm.2013.01.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/25/2013] [Accepted: 01/25/2013] [Indexed: 12/12/2022] Open
|
47
|
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune disorder of the peripheral nervous system. This article highlights our current understanding of the condition along with its phenotypic variants that are encountered in clinical practice. The diagnostic evaluation of CIDP includes laboratory studies to detect associated medical conditions and electrodiagnostic studies to assess for demyelination. Current treatment options include corticosteroids, plasma exchange, and intravenous immune globulin, along with alternative therapies that may be used as corticosteroid-sparing agents or for treatment-refractory cases. Approximately 85% to 90% of patients eventually improve or stabilize with treatment, and the long-term prognosis of CIDP is favorable.
Collapse
|
48
|
Abstract
PURPOSE OF REVIEW Over the past 25 years, many autoantibodies directed against peripheral nerve glycan and protein antigens have been described. Principally through this area of research, significant advances have been achieved in the understanding of the pathophysiology of inflammatory neuropathies. More evidence constantly continues to emerge supporting the role of antibodies in pathogenesis. This review reports the recent studies highlighting the complex association between autoantibodies directed against various peripheral nerve antigens and immune polyneuropathies. RECENT FINDINGS The discovery of serum antibodies directed against ganglioside and glycolipid complexes has generated huge interest in this area of research. The expectation that nodal proteins are important targets continues to be pursued in line with the improvements in detection methodology. Basic studies continue to support a direct role for autoantibodies in neuropathy pathogenesis. SUMMARY Discovery of new target epitopes has not only raised hopes for further improvement in our understanding of pathophysiology and availability of new diagnostic markers, but also for future targeted therapies. Further studies are required to elucidate the precise pathological and clinical significance of these new antibodies.
Collapse
|
49
|
Querol L, Nogales-Gadea G, Rojas-Garcia R, Martinez-Hernandez E, Diaz-Manera J, Suárez-Calvet X, Navas M, Araque J, Gallardo E, Illa I. Antibodies to contactin-1 in chronic inflammatory demyelinating polyneuropathy. Ann Neurol 2012; 73:370-80. [PMID: 23280477 DOI: 10.1002/ana.23794] [Citation(s) in RCA: 246] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/15/2012] [Accepted: 09/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a frequent autoimmune neuropathy with a heterogeneous clinical spectrum. Clinical and experimental evidence suggests that autoantibodies may be involved in its pathogenesis, but the target antigens are unknown. Axoglial junction proteins have been proposed as candidate antigens. We examined the reactivity of CIDP patients' sera against neuronal antigens and used immunoprecipitation for antigen unraveling. METHODS Primary cultures of hippocampal neurons were used to select patients' sera that showed robust reactivity with the cell surface of neurons. The identity of the antigens was established by immunoprecipitation and mass spectrometry, and subsequently confirmed with cell-based assays, immunohistochemistry with teased rat sciatic nerve, and immunoabsorption experiments. RESULTS Four of 46 sera from patients with CIDP reacted strongly against hippocampal neurons (8.6%) and paranodal structures on peripheral nerve. Two patients' sera precipitated contactin-1 (CNTN1), and 1 precipitated both CNTN1 and contactin-associated protein 1 (CASPR1). Reactivity against CNTN1 was confirmed in 2 cases, whereas the third reacted only when CNTN1 and CASPR1 were cotransfected. No other CIDP patient or any of the 104 controls with other neurological diseases tested positive. All 3 patients shared common clinical features, including advanced age, predominantly motor involvement, aggressive symptom onset, early axonal involvement, and poor response to intravenous immunoglobulin. INTERPRETATION Antibodies against the CNTN1/CASPR1 complex occur in a subset of patients with CIDP who share common clinical features. The finding of this biomarker may help to explain the symptoms of these patients and the heterogeneous response to therapy in CIDP.
Collapse
Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Mehndiratta MM, Hughes RAC. Plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2012:CD003906. [PMID: 22972066 DOI: 10.1002/14651858.cd003906.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an uncommon progressive or relapsing paralysing disease caused by inflammation of the peripheral nerves. If the hypothesis that it is due to autoimmunity is correct, removal of autoantibodies in the blood by plasma exchange should be beneficial. OBJECTIVES To evaluate the efficacy of plasma exchange in CIDP. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 May 2012), CENTRAL (2012, Issue 4), MEDLINE (January 1966 to May 2012), EMBASE (January 1980 to May 2012), CINAHL Plus (January 1937 to May 2012) and LILACS (January 1982 to May 2012). We also scrutinised the bibliographies of the trials, and contacted the trial authors and other disease experts. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs in participants of any age comparing plasma exchange with sham treatment or no treatment. DATA COLLECTION AND ANALYSIS Two authors selected the trials, extracted the data and assessed risk of bias independently. Where possible data were combined according to the methods of the Cochrane Neuromuscular Disease Review Group. PRIMARY OUTCOME MEASURE one cross-over trial including 18 participants showed two (95% confidence interval (CI) 0.8 to 3.0) points more improvement after four weeks on an 11-point disability scale with plasma exchange (10 exchanges over four weeks) than with sham exchange. Rapid deterioration after plasma exchange occurred in eight of 12 who had improved. SECONDARY OUTCOME MEASURES when the results of this trial and another with 29 participants treated in a parallel group design trial were combined, there were 31 points (95% CI 16 to 45, maximum score 280) more improvement in an impairment scale after plasma exchange (six exchanges over three weeks) than after sham exchange. There were significant improvements in both trials in an electrophysiological measure, the proximally evoked compound muscle action potential, after three or four weeks. Non-randomised evidence indicates that plasma exchange induces adverse events in 3% to 17% of procedures. These are sometimes serious. A trial showing no significant difference in the benefit between plasma exchange and intravenous immunoglobulin has been included in the Cochrane review of intravenous immunoglobulin for this condition. AUTHORS' CONCLUSIONS Moderate to high quality evidence from two small trials showed that plasma exchange provides significant short-term improvement in disability, clinical impairment and motor nerve conduction velocity in CIDP but rapid deterioration may occur afterwards. Adverse events related to difficulty with venous access, use of citrate and haemodynamic changes are not uncommon. More research is needed to identify agents which will prolong the beneficial action of plasma exchange.
Collapse
|