Neurologic indications for therapeutic plasma exchange: An update

Therapeutic Plasma Exchange as a Treatment for Autoimmune Neurological Disease

Introduction

Therapeutic plasma exchange (TPE) is commonly used as treatment of certain autoimmune neurological diseases (ANDs), and its main objective is the removal of pathogenic autoantibodies. Our aim was to describe the clinical profile and the experience with the usage of TPE in patients with ANDs at our institution.

Methods

This is an observational retrospective study, including medical records of patients with diagnosis of ANDs who received TPE, between 2011 and 2018. Characteristics of TPE, such as number of cycles, type of replacement solution, and adverse effects, were evaluated. The modified Rankin Scale (mRS) was applied to measure the clinical response after the therapy.

Results

187 patients were included with the following diagnoses: myasthenia gravis (MG), n = 70 (37%); Guillain–Barré syndrome (GBS), n = 53 (28.3%), neuromyelitis optica spectrum disorders (NMOSD), n = 35 (18.7%); chronic inflammatory demyelinating polyneuropathy (CIDP), n = 23 (12.2%); and autoimmune encephalitis (AE), n = 6 (3.2%). The most used types of replacement solution were albumin (n = 131, 70%) and succinylated gelatin (n = 45, 24%). All patients received a median of five cycles (IQR 5-5). Hypotension and hydroelectrolytic disorders were the main complications. After TPE, 99 patients (52.9%) showed improvement in the mRS scores and a statistical significance (p < 0.05) was seen between the admission score and after TPE for every diagnosis except for CIDP.

Conclusion

TPE has an adequate safety profile, and improvement in functionality in treated patients reflects its effectiveness.

Impact of the hematocrit value of the blood prime unit on patient hematocrit values after therapeutic plasma exchange in children weighing 10 kg or less

We report the impact of measuring the hematocrit (HCT) of blood prime units (BPUs) on postprocedure patient HCT values in a small child with transverse myelitis undergoing therapeutic plasma exchange (TPE). Initially, the BPU HCT values were not measured, according to our apheresis policy of using our blood center's estimated HCT value. This approach resulted in unexpected increasing elevations of our patient's post-TPE HCT after the first two TPE procedures. Subsequent measurement of the BPU HCT prior to use stabilized the patient's post-TPE HCT. To our knowledge, this is the first case report describing the impact of using the measured BPU HCT vs the estimated HCT for very small children undergoing therapeutic apheresis. Our standard operating procedure for very small children has been updated after this patient's case to include measurements of the HCT values of BPUs for children who weigh 10 kg or less.

Feasibility of Monotherapy by Rituximab Without Additional Desensitization in ABO-incompatible Living-Donor Liver Transplantation

BACKGROUND

Rituximab is a cornerstone in the regimens of desensitization for ABO-incompatible living-donor liver transplantation (ABO-i LDLT) that makes this modality an acceptable option for liver transplantation. Plasmapheresis (PP) to reduce anti-ABO antibody titer and local infusion (LI) therapy were practiced as the strategies for desensitization before the application of rituximab and were reported as additional treatments. The aim of this study was to clarify the feasibility of monotherapy by rituximab without any additional desensitization treatments in ABO-i LT.

METHODS

Forty patients receiving ABO-i LDLT with rituximab were enrolled in this retrospective study. The patients were divided into 2 groups: the rituximab with pretransplant PP and posttransplant LI (RPL) group (n = 20) and the rituximab monotherapy (RM) without any additional treatment group (n = 20). The groups were then compared in terms of the rates of patient survival, antibody-mediated rejection (AMR), and infection.

RESULTS

The 1-, 3-, and 5-year patient survival rates were 85%, 85%, and 85% in the RPL group and 89%, 80%, and 80% in the RM group, respectively. There was no significant difference in patient survival between the 2 groups. There were no episodes of AMR in either group. The RM group had a lower rate of fungal and viral infections than the RPL group.

CONCLUSIONS

Pretransplant rituximab without additional treatments yielded satisfactory outcomes comparable to that with additional treatments, such as PP and LI.

Remitting long-standing major depression in a multiple sclerosis patient with several concurrent conditions

In this report, we discuss the case of an multiple sclerosis (MS) patient, age 62, who learned to attain and sustain euthymia despite his ailments. He has Ehlers Danlos Syndrome (EDS), asthma, MS, urticaria, and major depression (MD). Despite thriving limitations, the patient is an accomplished scientist, who struggled for > twelve years to emerge from being confined to bed and wheel chair with MS, to walking with crutches, scuba diving, writing manuscripts, and living a positive life. Through former educators, he reacquired problem-solving habits to study the literature on his illnesses; keep records; try new therapies; and use pharmaceutical, nutritional, physical, and psychological methods to attain euthymia. With this inculcation, years later, he discovered that dimethyl fumarate (DMF) suppressed inflammation, cramping, urticaria, and asthma; and the combination of bupropion, S-adenosylmethionine (SAMe), vitamin-D3 (vit-D3), yoga, and self-hypnosis relieved MD. Then, after a 14-month respite, the patient, discovered that he had adult onset craniopharyngioma: a benign, recurring, epithelial tumor that grows from vestigial embryonic tissue (Rathke's pouch) which formed the anterior pituitary. The tumor grows aggressively and causes surrounding tissue and function losses. It caused headaches, disorientation, bitemporal vision loss, among other problems. To emerge from this conundrum, the patient employed his relearned habits; the above antidepressant cocktail (bupropion, SAMe, and vit-D3); and with 30 fractionated stereotactic radiation treatments shrank his tumor and gained relief. This is a single case, and methods we discovered serendipitously may not work for other chronically ill patients. Consequently, we want to encourage such patients and their physicians to discuss their experiences in peer-reviewed domains so readers may acquire new perspectives that help individualize their care, and have productive contented lives.

Current topics in therapeutic plasmapheresis

Therapeutic plasmapheresis has been used for intractable diseases that cannot be cured by conventional drug therapy. Currently, the use of therapeutic plasmapheresis has been approved for 27 diseases by Japan's National Health Insurance system and is mainly categorized into three modalities: plasma exchange (PE), double-filtration plasmapheresis (DFPP), and plasma adsorption (PA). Plasma separators and/or fractionators are essential for the therapy. PE is performed for two purposes: removal of pathogenic antigens or substances in the plasma fraction and supplementation of essential factors, such as albumin and coagulation factors. PE can be used for thrombotic microangiopathy and acute hepatic failure. DFPP can be performed for selective removal of macromolecules while avoiding the use of substitution fluid (i.e., albumin or fresh frozen plasma). DFPP has now been used for conditions involving relatively larger plasma molecules, including hyperviscosity syndrome and ABO-incompatible kidney transplantation. PA can specifically remove pathogenic agents, such as low-density lipoprotein or autoantibodies, in the IgG fractions by the adsorption column and does not require substitution fluids. PA has now been used for a wide variety of neurological diseases, including chronic inflammatory demyelinating polyneuropathy. This review describes the characteristics of each modality, seeking to improve the efficacy and specificity of removal of the target substance.

Missing links in multiple sclerosis etiology. A working connecting hypothesis

The etiology of multiple sclerosis is still elusive despite an extended patchwork of mechanistic events has been accumulated. In this article, are tentatively identified from scattered literature sources new factors that may link well known characteristic of MS such as the central alteration of BBR selectivity, its association with EBV status and its biased distribution of the globe more comprehensively. The hypothesis proposes that the concomitant important rise in some heterophilic antibodies (anti Neu5Gc) which activate BBB endothelial cells and in the frequency of anti EBV committed T cells and of memory B infected cells with EBV contemporary to EBV infection play a major role in MS etiology. In addition, the hypothesis proposes new possible explanations for the elevated risk of MS in specific geographical area.

Current options for the treatment of optic neuritis

Optic neuritis can be defined as typical (associated with multiple sclerosis, improving independent of steroid treatment), or atypical (not associated with multiple sclerosis, steroid-dependent improvement). Causes of atypical optic neuritis include connective tissue diseases (eg, lupus), vasculitis, sarcoidosis, or neuromyelitis optica. In this manuscript, updated treatment options for both typical and atypical optic neuritis are reviewed. Conventional treatments, such as corticosteroids, therapeutic plasma exchange, and intravenous immunoglobulin therapy are all discussed with commentary regarding evidence-based outcomes. Less commonly used treatments and novel purported therapies for optic neuritis are also reviewed. Special scenarios in the treatment of optic neuritis – pediatric optic neuritis, acute demyelinating encephalomyelitis, and optic neuritis occurring during pregnancy – are specifically examined.

Update on neuromyelitis optica: natural history and management

Neuromyelitis optica or Devic disease is an inflammatory disorder of the central nervous system. It is caused by antibodies that attack aquaporin 4 water channels in the cell membrane of astrocytic foot processes at the blood brain barrier. It can involve the optic nerve, the spinal cord and beyond. Here we review its pathophysiology, clinical features, and therapy.