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Lin Y, Oji S, Miyamoto K, Narita T, Kameyama M, Matsuo H. Real-world application of plasmapheresis for neurological disease: Results from the Japan-Plasmapheresis Outcome and Practice Patterns Study. Ther Apher Dial 2023; 27:123-135. [PMID: 35765859 PMCID: PMC10084057 DOI: 10.1111/1744-9987.13906] [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: 03/25/2022] [Accepted: 06/22/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Plasmapheresis is a well-recognized treatment for autoimmune neurological diseases in Japan. However, the practice varies depending on the facility, and the actual treatment conditions are unclear. METHODS To clarify real-world conditions, a prospective observational study was conducted on patients with neurological diseases who were scheduled to receive plasmapheresis. A dataset was analyzed that included 887 treatments from 210 patients with myasthenia gravis (MG), multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and other diseases for 82, 30, 24, and 74 patients, respectively. RESULTS The types of plasmapheresis performed included immunoadsorption plasmapheresis, plasma exchange, and double filtration plasmapheresis with 620, 213, and 54 treatments, respectively. Approximately, 60% of the treatments were performed using peripheral blood access alone. Non-serious adverse events were observed in 10 patients. CONCLUSIONS A statistically significant improvement was observed after plasmapheresis in patients with MG, MS, and NMOSD. These were evaluated using the modified Rankin Scale.
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Affiliation(s)
- Youwei Lin
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan.,Department of Immunology, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Satoru Oji
- Department of Neurology, Saitama Medical Center, Kawagoe, Japan
| | | | - Tomoko Narita
- Department of Neurology, Nagasaki Kawatana Medical Center, Kawatana, Japan
| | - Mana Kameyama
- Clinical Development Department, Asahi-Kasei Medical Co., Tokyo, Japan
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, Kawatana, Japan.,Department of Neurology, Nagasaki National Hospital, Nagasaki, Japan
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2
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Boada M, Kiprov D, Anaya F, López OL, Núñez L, Olazarán J, Lima J, Grifols C, Barceló M, Rohe R, Prieto-Fernández C, Szczepiorkowski ZM, Páez A. Feasibility, safety, and tolerability of two modalities of plasma exchange with albumin replacement to treat elderly patients with Alzheimer's disease in the AMBAR study. J Clin Apher 2023; 38:45-54. [PMID: 36305459 PMCID: PMC10092802 DOI: 10.1002/jca.22026] [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: 05/17/2022] [Revised: 09/14/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the Alzheimer Management by Albumin Replacement (AMBAR) study, mild-to-moderate Alzheimer's disease (AD) patients were treated with a plasma exchange (PE) program. Feasibility and safety of PE in this specific population are poorly understood and were analyzed in detail in this study. METHODS Qualified patients were treated with 6 weeks of weekly conventional therapeutic plasma exchange (TPE) with albumin replacement followed by monthly low-volume plasma exchange (LVPE) for 12 months. The patients were divided into four groups: placebo (sham PE treatment), low-albumin (20 g), low-albumin + intravenous immunoglobulin (IVIG) (10 g), and high-albumin (40 g) + IVIG (20 g). Adverse events (AEs) were recorded and analyzed for all PE treatment groups and PE modalities. RESULTS PE procedure-related AEs were more common in the active treatment groups (16.9% out of 1283 TPE and 12.5% out of 2203 LVPE were associated with at least one AE, a similar rate than in other PE indications) than in the placebo group (0.7% out of 1223 sham PE). Percentage of procedures with at least one AEs was higher with central venous access compared to peripheral venous access in all three active treatment groups (20.1% vs 13.1%, respectively). CONCLUSION The TPE and LVPE procedures used in the AMBAR study on mild-to-moderate AD population were as safe and feasible as in other therapeutic applications of PE or routine plasmapheresis.
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Affiliation(s)
- Mercè Boada
- Ace Alzheimer Center Barcelona - Universitat Internacional de Catalunya, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Dobri Kiprov
- Apheresis Care Group and Fresenius Medical Care, San Francisco, California, USA
| | - Fernando Anaya
- Nephrology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar L López
- Departments of Neurology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura Núñez
- Alzheimer's Research Group, Grifols, Barcelona, Spain
| | - Javier Olazarán
- Neurology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Memory Disorders Clinic, HM Hospitales, Madrid, Spain
| | - José Lima
- American Red Cross Southern Blood Services Region, Atlanta, Georgia, USA
| | | | | | - Regina Rohe
- Apheresis Care Group and Fresenius Medical Care, San Francisco, California, USA
| | | | - Zbigniew M Szczepiorkowski
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Antonio Páez
- Alzheimer's Research Group, Grifols, Barcelona, Spain
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3
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Fernández-Fournier M, Kerguelen A, Rodríguez de Rivera FJ, Lacruz L, Jimeno S, Losantos I, Hernández-Maraver D, Puertas I, Tallon-Barranco A, Viejo A, Frank García A, Díez-Tejedor E. Therapeutic plasma exchange for myasthenia gravis, Guillain-Barre syndrome, and other immune-mediated neurological diseases, over a 40-year experience. Expert Rev Neurother 2022; 22:897-903. [PMID: 36408604 DOI: 10.1080/14737175.2022.2147827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) was first used in neurology in the 1980s for myasthenia gravis (MG) and Guillain-Barré syndrome (GBS). Indications have since grown. Fear of complications with this treatment modality limit its use. RESEARCH DESIGN & METHODS A study of patients undergoing TPE for neurological diseases (1981-2020) in a University Hospital in Madrid, Spain. Clinical indications, complications, procedure number, apheresis technique and replacement fluids were prospectively recorded and retrospectively analyzed. Historical trends were studied. RESULTS 159 patients (48.69 ±18.15 years, 54.3% females) underwent TPE using central-venous catheter and replacement fluid albumin. We performed 1207 procedures over 189 cycles (6.4 ±3.8 procedures/cycle). Most patients underwent TPE for category I-II indications, mainly GBS and MG (77.7%). Complication rate was low (3.9% procedures), mostly hypotensive/vasovagal reactions (55.3%) and vascular access-related complications (38.3%). Most were mild-moderate (92.9%), permitting TPE completion, and somewhat more frequent during the first procedure (38.3%) and after periods of little TPE use. GBS patients were more prone to complications than MG patients (6.5% vs. 1.2%,p<0.001) mainly hypotensive/vasovagal reactions (3.7% vs. 1.0%,p=0.008). CONCLUSIONS TPE is well-tolerated with low complication rate (<4% procedures), mainly hypotensive/vasovagal reactions. Patients with GBS seem more prone to them than MG patients. Acquaintance with this technique seems necessary.
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Affiliation(s)
- Mireya Fernández-Fournier
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Ana Kerguelen
- Apheresis Unit, Department of Haematology, Hospital Universitario La Paz, Spain
| | - Francisco Javier Rodríguez de Rivera
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Laura Lacruz
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Santiago Jimeno
- Apheresis Unit, Department of Haematology, Hospital Universitario La Paz, Spain
| | - Itsaso Losantos
- Biostatistics Section, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | | | - Inmaculada Puertas
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Antonio Tallon-Barranco
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Aurora Viejo
- Apheresis Unit, Department of Haematology, Hospital Universitario La Paz, Spain
| | - Ana Frank García
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
| | - Exuperio Díez-Tejedor
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario La Paz & Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain
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4
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Povedano M, Paipa A, Barceló M, Woodward MK, Ortega S, Domínguez R, Aragonés ME, Horrillo R, Costa M, Páez A. Plasma exchange with albumin replacement and disease progression in amyotrophic lateral sclerosis: a pilot study. Neurol Sci 2021; 43:3211-3221. [PMID: 34791571 PMCID: PMC9018657 DOI: 10.1007/s10072-021-05723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Abstract
Background Plasma exchange (PE) is used to treat a range of neurological disorders. Based on results demonstrated in Alzheimer’s disease, we theorized that PE with albumin replacement (PE-A) might alter the metabolic profile of plasma and cerebrospinal fluid in patients with amyotrophic lateral sclerosis (ALS) by removing disease-inducing molecules. The aim of this study was to evaluate the effect of PE-A on disease progression in ALS. Methods In this open-label, non-controlled, single-arm, prospective pilot study, 13 adults with ALS had 6 months’ treatment with PE-A 5% and 6 months’ follow-up. Primary endpoints were changes from baseline in the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) score and forced vital capacity (FVC) through 48 weeks. A post hoc analysis compared individual patient data with the expected ALSFRS-R progression slope. Results The median ALSFRS-R score declined throughout the study, although the rate of decline was slower than expected in seven patients at treatment end and in five patients at study end. Six patients remained in the same baseline slope progression category, and four patients improved their slope category at treatment end. Median FVC decreased significantly during the study. Treatment was well tolerated. Of 330 PE-A procedures, 0.9% were associated with potentially related adverse events. Conclusion Although functional impairment progressed, about two-thirds of patients showed a slower than expected rate of decline at treatment end. Most patients had unaltered (54.5%) or reduced (36.4%) ALSFRS-R slope progression at treatment end. Further evaluation of PE-A in controlled studies involving more patients is warranted. EudraCT number 2013-004842-40. Trial registration ClinicalTrials.gov identifier: NCT02479802.
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Affiliation(s)
- Mónica Povedano
- Department of Neurology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Andrés Paipa
- Department of Neurology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Miquel Barceló
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Sandra Ortega
- Department of Apheresis, Banc de Sang i Teixits, Barcelona, Spain
| | - Raúl Domínguez
- Department of Neurology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Raquel Horrillo
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Antonio Páez
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
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5
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Costa M, Páez A. Emerging insights into the role of albumin with plasma exchange in Alzheimer's disease management. Transfus Apher Sci 2021; 60:103164. [PMID: 34083161 DOI: 10.1016/j.transci.2021.103164] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Alzheimer's disease (AD) is a neurodegenerative process that inexorably leads to progressive deterioration of cognition function and, ultimately, death. Central pathophysiologic features of AD include the accumulation of extracellular plaques comprised of amyloid-β peptide (Aβ) and the presence of intraneuronal neurofibrillary tangles. However, a large body of evidence suggests that oxidative stress and inflammation are major contributors to the pathogenesis and progression of AD. To date, available pharmacologic treatments are only symptomatic. Clinical trials focused on amyloid and non-amyloid-targeted treatments with small molecule pharmacotherapy and immunotherapies have accumulated a long list of failures. Considering that around 90 % of the circulating Aβ is bound to albumin, and that a dynamic equilibrium exists between peripheral and central Aβ, plasma exchange with albumin replacement has emerged as a new approach in a multitargeted AD therapeutic strategy (AMBAR Program). In plasma exchange, a patient's plasma is removed by plasmapheresis to eliminate toxic endogenous substances, including Aβ and functionally impaired albumin. The fluid replacement used is therapeutic albumin, which acts not only as a plasma volume expander but also has numerous pleiotropic functions (e.g., circulating Aβ- binding capacity, transporter, detoxifier, antioxidant) that are clinically relevant for the treatment of AD. Positive results from the AMBAR Program (phase 1, 2, an 2b/3 trials), i.e., slower decline or stabilization of disease symptoms in the most relevant clinical efficacy and safety endpoints, offer a glimmer of hope to both AD patients and caregivers.
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Affiliation(s)
| | - Antonio Páez
- Alzheimer's Research Group, Grifols, Barcelona, Spain.
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6
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Boada M, López OL, Olazarán J, Núñez L, Pfeffer M, Paricio M, Lorites J, Piñol-Ripoll G, Gámez JE, Anaya F, Kiprov D, Lima J, Grifols C, Torres M, Costa M, Bozzo J, Szczepiorkowski ZM, Hendrix S, Páez A. A randomized, controlled clinical trial of plasma exchange with albumin replacement for Alzheimer's disease: Primary results of the AMBAR Study. Alzheimers Dement 2020; 16:1412-1425. [PMID: 32715623 PMCID: PMC7984263 DOI: 10.1002/alz.12137] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/20/2020] [Accepted: 06/04/2020] [Indexed: 12/19/2022]
Abstract
Introduction This phase 2b/3 trial examined the effects of plasma exchange (PE) in patients with mild‐to‐moderate Alzheimer's disease (AD). Methods Three hundred forty‐seven patients (496 screened) were randomized (1:1:1:1) into three PE treatment arms with different doses of albumin and intravenous immunoglobulin replacement (6‐week period of weekly conventional PE followed by a 12‐month period of monthly low‐volume PE), and placebo (sham). Results PE‐treated patients performed significantly better than placebo for the co‐primary endpoints: change from baseline of Alzheimer's Disease Cooperative Study–Activities of Daily Living (ADCS‐ADL; P = .03; 52% less decline) with a trend for Alzheimer's Disease Assessment Scale–Cognitive Subscale (ADAS‐Cog; P = .06; 66% less decline) scores at month 14. Moderate‐AD patients (baseline Mini‐Mental State Examination [MMSE] 18‐21) scored better on ADCS‐ADL (P = .002) and ADAS‐Cog (P = .05), 61% less decline both. There were no changes in mild‐AD patients (MMSE 22‐26). PE‐treated patients scored better on the Clinical Dementia Rating Sum of Boxes (CDR‐sb) (P = .002; 71% less decline) and Alzheimer's Disease Cooperative Study‐Clinical Global Impression of Change (ADCS‐CGIC) (P < .0001; 100% less decline) scales. Discussion This trial suggests that PE with albumin replacement could slow cognitive and functional decline in AD, although further studies are warranted.
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Affiliation(s)
- Mercè Boada
- Research Center and Memory Clinic, Fundació ACE, Institut Català de Neurociències Aplicades - Universitat Internacional de Catalunya, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Oscar L López
- Departments of Neurology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Javier Olazarán
- Neurology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Memory Disorders Unit - HM Hospitals, Madrid, Spain
| | - Laura Núñez
- Alzheimer's Research Group, Grifols, Barcelona, Spain
| | - Michael Pfeffer
- Medical Services, Allied Biomedical Research Institute, Inc., Miami, Florida, USA
| | - María Paricio
- Center for Prevention of Alzheimer´s Disease, Miami Dade Medical Research Institute, Miami, Florida, USA
| | - Jesús Lorites
- Medical Services, L&L Research Choices, Inc., Miami, Florida, USA
| | - Gerard Piñol-Ripoll
- Seizure Disorders Unit, Clinical Neuroscience Research, IRBLleida-Hospital Universitari Santa Maria, Lleida, Spain
| | - José E Gámez
- Psychiatry Department, Galiz Research, Hialeah, Florida, USA
| | - Fernando Anaya
- Nephrology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Dobri Kiprov
- Apheresis Care Group and Fresenius Medical Care, San Francisco, California, USA
| | - José Lima
- American Red Cross Southern Blood Services Region, Atlanta, Georgia, USA
| | | | - Mireia Torres
- Alzheimer's Research Group, Grifols, Barcelona, Spain
| | | | - Jordi Bozzo
- Alzheimer's Research Group, Grifols, Barcelona, Spain
| | - Zbigniew M Szczepiorkowski
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Antonio Páez
- Alzheimer's Research Group, Grifols, Barcelona, Spain
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7
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Loeffler DA. AMBAR, an Encouraging Alzheimer's Trial That Raises Questions. Front Neurol 2020; 11:459. [PMID: 32547478 PMCID: PMC7272580 DOI: 10.3389/fneur.2020.00459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 04/29/2020] [Indexed: 12/18/2022] Open
Abstract
Grifols' recent Alzheimer Management by Albumin Replacement (“AMBAR”) study investigated the effects of plasmapheresis with albumin replacement, plus intravenous immunoglobulin (IVIG) in some subjects, in patients with mild-to-moderate Alzheimer's disease (AD). AMBAR was a phase IIb trial in the United States and a phase III trial in Europe. There were three treatment groups (plasmapheresis with albumin replacement; plasmapheresis with low dose albumin and IVIG; plasmapheresis with high dose albumin and IVIG) and sham-treated controls. Disease progression in pooled treated patients was 66% less than control subjects based on ADAS-Cog scores (p = 0.06) and 52% less based on ADCS-ADL scores (p = 0.03). Moderate AD patients had 61% less progression, based on both ADAS-Cog and ADCS-ADL scores, than their sham-treated counterparts (p-values 0.05 and 0.002), and their CDR-Sb scores declined 53% less than their sham-treated counterparts. However, ADAS-Cog and ADCS-ADL scores were not significantly different between actively-treated and sham-treated mild AD patients, although CDR-Sb scores improved vs. baseline for treated mild AD patients. Patients administered both IVIG and albumin had less reduction in brain glucose metabolism than sham-treated patients. Questions raised by these findings include: what mechanism(s) contributed to slowing of disease progression? Is this approach as effective in mild AD as in moderate AD? Must IVIG be included in the protocol? Does age, sex, or ApoE genotype influence treatment response? Does the protocol increase the risk for amyloid-related imaging abnormalities? How long does disease progression remain slowed post-treatment? A further study should allow this approach to be optimized.
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Affiliation(s)
- David A Loeffler
- Beaumont Research Institute, Department of Neurology, Beaumont Health, Royal Oak, MI, United States
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8
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Therapeutic apheresis within immune-mediated neurological disorders: dosing and its effectiveness. Sci Rep 2020; 10:7925. [PMID: 32404917 PMCID: PMC7220931 DOI: 10.1038/s41598-020-64744-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
Plasma exchange (PE) and immunoadsorption (IA) are standard therapeutic options of immune-mediated neurological disorders. This study evaluates the relation of the relative quantity of applied dose of PE and/ or IA and its achieved therapeutic effectiveness within the treated underlying neurological disorders. In a retrospective study, we evaluated data from PE and IA carried out 09/2009-06/2014 in neurological patients at the University-Hospital of Saarland, Germany. Apheresis dose was defined as the ratio of the extracorporeal treated plasma volume to the patient's plasma volume. Effectiveness was assessed through disease-specific tests and scores by the attending neurologist(s); results were classified into response or no response. 1101 apheresis (PE:238, IA:863), in 153 hospital-stays were carried out, averaged, 7.0 treatments per patients, 82% responded, 18% not. Mean applied apheresis dose per treatment was 0.91 with mean doses of 1.16 for PE and 0.81 for IA. The totally applied mean dose per stay was 5.6 (PE:5.01, IA:5.81). No correlation was seen between apheresis dosing and treatment effectiveness (PE:R2 = 0.074, IA:R2 = 0.0023). PE and IA in therapy-refractory immune-mediated neurological disorders majorly achieved a measurable severity improvement - without correlation to the applied dose. Moreover, our data rather suggest, that effectiveness may be given with volumes below currently recommended volumes.
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9
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Imbimbo BP, Ippati S, Ceravolo F, Watling M. Perspective: Is therapeutic plasma exchange a viable option for treating Alzheimer's disease? ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12004. [PMID: 32211508 PMCID: PMC7087432 DOI: 10.1002/trc2.12004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/15/2020] [Accepted: 01/28/2020] [Indexed: 12/19/2022]
Abstract
Therapeutic plasma exchange, consisting of removing blood plasma and exchanging it with donated blood products, has been proposed for treating Alzheimer's disease (AD) to remove senescent or toxic factors. In preclinical studies, administration of plasma from young healthy mice to AD transgenic mice improved cognitive deficits without affecting brain amyloid plaques. Initial encouraging results have been collected in a double-blind, placebo-controlled study in nine AD patients receiving young plasma. In a 14-month double-blind, placebo-controlled study in 322 AD patients, multiple infusions with plasma enriched with albumin with or without immunoglobulins slowed cognitive, functional, and clinical decline, especially in moderately affected patients. Clinical trials of plasma fractions containing hypothetically beneficial proteins are also under way. These initial positive clinical results need to be confirmed in larger and more rigorous controlled studies in which the possible benefits of plasma exchange approaches can be weighed against the intrinsic side effects of repetitive infusion procedures.
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Affiliation(s)
- Bruno P. Imbimbo
- Department of Research and DevelopmentChiesi FarmaceuticiParmaItaly
| | - Stefania Ippati
- Experimental Imaging CenterSan Raffaele Scientific InstituteMilanItaly
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10
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Abstract
Paraneoplastic neurological syndromes are nonmetastatic complications of malignancy secondary to immune-mediated neuronal dysfunction or death. Pathogenesis may occur from cell surface binding of antineuronal antibodies leading to dysfunction of the target protein, or from antibodies binding against intracellular antigens which ultimately leads to cell death. There are several classical neurological paraneoplastic phenotypes including subacute cerebellar degeneration, limbic encephalitis, encephalomyelitis, and dorsal sensory neuropathy. The patient’s clinical presentations may be suggestive to the treating clinician as to the specific underlying paraneoplastic antibody. Specific antibodies often correlate with the specific underlying tumor type, and malignancy screening is essential in all patients with paraneoplastic neurological disease. Prompt initiation of immunotherapy is essential in the treatment of patients with paraneoplastic neurological disease, often more effective in cell surface antibodies in comparison to intracellular antibodies, as is removal of the underlying tumor.
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Affiliation(s)
- Jonathan Galli
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA.,2. George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - John Greenlee
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA
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11
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Moser T, Harutyunyan G, Karamyan A, Otto F, Bacher C, Chroust V, Leitinger M, Novak HF, Trinka E, Sellner J. Therapeutic Plasma Exchange in Multiple Sclerosis and Autoimmune Encephalitis: a Comparative Study of Indication, Efficacy and Safety. Brain Sci 2019; 9:brainsci9100267. [PMID: 31601005 PMCID: PMC6827054 DOI: 10.3390/brainsci9100267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is a well-established method of treatment for steroid-refractory relapses in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Little is known about indications and clinical responses to TPE in autoimmune encephalitis and other immune-mediated disorders of the central nervous system (CNS). We performed a retrospective chart review of patients with immune-mediated disorders of the CNS undergoing TPE at our tertiary care center between 2003 and 2015. The response to TPE within a 3- to 6-month follow-up was scored with an established rating system. We identified 40 patients including 21 patients with multiple sclerosis (MS, 52.5%), 12 with autoimmune encephalitis (AE, 30%), and 7 with other immune-mediated CNS disorders (17.5%). Among patients with AE, eight patients had definite AE (Immunolobulin G for N-methyl-D-aspartate receptor n = 4, Leucine-rich, glioma inactivated 1 n = 2, Ma 2 n = 1, and Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid n = 1). Intravenous immunoglobulins had been given prior to TPE in all but one patient with AE, and indications were dominated by acute psychosis and epileptic seizures. While TPE has a distinct place in the treatment sequence of different immune-mediated CNS disorders, we found consistent efficacy and safety. Further research should be directed toward alternative management strategies in non-responders.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Gayane Harutyunyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Anush Karamyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Ferdinand Otto
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Carola Bacher
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Vaclav Chroust
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 Mücnhen, Germany.
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria.
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12
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Lipphardt M, Mühlhausen J, Kitze B, Heigl F, Mauch E, Helms HJ, Müller GA, Koziolek MJ. Immunoadsorption or plasma exchange in steroid-refractory multiple sclerosis and neuromyelitis optica. J Clin Apher 2019; 34:381-391. [PMID: 30698295 DOI: 10.1002/jca.21686] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma exchange (PE) and immunoadsorption (IA) are alternative treatments of steroid-refractory relapses of multiple sclerosis (MS) or neuromyelitis optica (NMO). METHODS Adverse events and neurological follow-ups in 127 MS- (62 PE, 65 IA) and 13 NMO- (11 PE, 2 IA) patients were retrospectively analyzed. Response was defined by improvements in either expanded disability status scale (EDSS) by at least 1.0 or visual acuity (VA) to 0.5, confirmed after 3 and/or 6 months. RESULTS Hundred and forty patients were included in safety analysis, 102 patients provided sufficient neurological follow-up-data. There were no significant differences between IA and PE in side effects (3.9% vs 3.6%, P = .96) or response-rate (P = .65). Responders showed significant lower age (P = .02) and earlier apheresis-initiation (P = .01). Subgroup-analysis confirmed significant lower age in patients with relapsing-remitting MS (RRMS) /clinical isolated syndrome (CIS). CONCLUSION IA and PE seem equally safe and effective in steroid-resistant MS- or NMO-relapses. Early apheresis and low patient age are additional prognostic factors.
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Affiliation(s)
- Mark Lipphardt
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Johannes Mühlhausen
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Bernd Kitze
- Department of Neurology, Georg-August-University Göttingen, Germany
| | - Franz Heigl
- Department of Neurology, Medical Healthcare Centre Kempten, Kempten-Allgäu, Germany
| | - Erich Mauch
- Neurological Hospital Dietenbronn, Schwendi, Germany
| | - Hans-Joachim Helms
- Department of Medical Statistics, Georg-August-University Göttingen, Göttingen, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Michael J Koziolek
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
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13
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Levy M. Plasmapheresis for acute attacks in neuromyelitis optica spectrum disorders. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e510. [PMID: 30345335 PMCID: PMC6192694 DOI: 10.1212/nxi.0000000000000510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Michael Levy
- Department of Neurology, Johns Hopkins University, Baltimore, MD
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14
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Eyre M, Hacohen Y, Barton C, Hemingway C, Lim M. Therapeutic plasma exchange in paediatric neurology: a critical review and proposed treatment algorithm. Dev Med Child Neurol 2018; 60:765-779. [PMID: 29856068 DOI: 10.1111/dmcn.13925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED Therapeutic plasma exchange (TPE) has been a key immunotherapeutic strategy in numerous neurological syndromes, predominantly during the acute phase of illness. This paper reviews the indications, strength of evidence, and safety of TPE in children with neurological conditions. The rarity of these immune conditions in children, alongside an often incomplete understanding of their pathobiology, has limited the development of a robust scientific rationale for TPE therapy and the feasibility of conducting larger controlled trials. TPE continues to be used, but is a costly therapy with common adverse effects. Uncertainty remains over how to compare the different TPE methods, the optimal dosage of therapy, and monitoring and integration of TPE with other immunotherapies. Further studies are also required to define the indications and benefits of TPE and assess evolving technologies such as immunoadsorption. WHAT THIS PAPER ADDS Studies investigating therapeutic plasma exchange (TPE) are small and mainly uncontrolled. They provide evidence for the efficacy of TPE in childhood neuro-inflammatory conditions. TPE is generally well tolerated provided key adverse effects are anticipated and avoided. Systematic dosing and objective assessment of treatment effect should be priorities for future research.
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Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Carmen Barton
- Children's Kidney Service, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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15
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Kiessling P, Lledo-Garcia R, Watanabe S, Langdon G, Tran D, Bari M, Christodoulou L, Jones E, Price G, Smith B, Brennan F, White I, Jolles S. The FcRn inhibitor rozanolixizumab reduces human serum IgG concentration: A randomized phase 1 study. Sci Transl Med 2018; 9:9/414/eaan1208. [PMID: 29093180 DOI: 10.1126/scitranslmed.aan1208] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/28/2017] [Accepted: 09/27/2017] [Indexed: 12/13/2022]
Abstract
Pathogenic immunoglobulin G (IgG) autoantibodies characterize some human autoimmune diseases; their high concentration and long half-life are dependent on recycling by the neonatal Fc receptor (FcRn). Inhibition of FcRn is an attractive new treatment concept for IgG-mediated autoimmune diseases. Rozanolixizumab (UCB7665; CA170_01519.g57 IgG4P) is an anti-human FcRn monoclonal antibody. In cynomolgus monkeys, rozanolixizumab reduced IgG (maximum 75 to 90% by about day 10), was well tolerated, and did not increase risk of infection. We also report a first-in-human, randomized, double-blind, placebo-controlled, dose-escalating study of intravenous (IV) or subcutaneous (SC) rozanolixizumab in healthy subjects (NCT02220153). The primary objective was to evaluate safety and tolerability. Secondary objectives were assessment of rozanolixizumab pharmacokinetics and pharmacodynamics, including effects on circulating IgG concentrations. Forty-nine subjects were randomized to receive rozanolixizumab (n = 36) or placebo (n = 13) across six cohorts. The first three cohorts received IV doses, and the subsequent three cohorts received SC doses, of rozanolixizumab 1, 4, or 7 mg/kg (n = 6 for each cohort; plus n = 7 or 6 for placebo, respectively). The most frequent treatment-emergent adverse event [TEAE; headache, 14 of 36 (38.9%) subjects] was dose-dependent and more prominent after IV administration. Severe TEAEs occurred in four subjects, all in the highest-dose IV group [headache (n = 3) and back pain (n = 1)]. Rozanolixizumab pharmacokinetics demonstrated nonlinear increases with dose. There were sustained dose-dependent reductions in serum IgG concentrations (IV and SC rozanolixizumab). These data provide clinical evidence for the therapeutic potential of rozanolixizumab.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Stephen Jolles
- Department of Immunology, University Hospital of Wales, Cardiff CF14 4XW, UK
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16
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Stephenson J, Nutma E, van der Valk P, Amor S. Inflammation in CNS neurodegenerative diseases. Immunology 2018; 154:204-219. [PMID: 29513402 PMCID: PMC5980185 DOI: 10.1111/imm.12922] [Citation(s) in RCA: 568] [Impact Index Per Article: 94.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 02/22/2018] [Accepted: 02/28/2018] [Indexed: 12/11/2022] Open
Abstract
Neurodegenerative diseases, the leading cause of morbidity and disability, are gaining increased attention as they impose a considerable socioeconomic impact, due in part to the ageing community. Neuronal damage is a pathological hallmark of Alzheimer's and Parkinson's diseases, amyotrophic lateral sclerosis, Huntington's disease, spinocerebellar ataxia and multiple sclerosis, although such damage is also observed following neurotropic viral infections, stroke, genetic white matter diseases and paraneoplastic disorders. Despite the different aetiologies, for example, infections, genetic mutations, trauma and protein aggregations, neuronal damage is frequently associated with chronic activation of an innate immune response in the CNS. The growing awareness that the immune system is inextricably involved in shaping the brain during development as well as mediating damage, but also regeneration and repair, has stimulated therapeutic approaches to modulate the immune system in neurodegenerative diseases. Here, we review the current understanding of how astrocytes and microglia, as well as neurons and oligodendrocytes, shape the neuroimmune response during development, and how aberrant responses that arise due to genetic or environmental triggers may predispose the CNS to neurodegenerative diseases. We discuss the known interactions between the peripheral immune system and the brain, and review the current concepts on how immune cells enter and leave the CNS. A better understanding of neuroimmune interactions during development and disease will be key to further manipulating these responses and the development of effective therapies to improve quality of life, and reduce the impact of neuroinflammatory and degenerative diseases.
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Affiliation(s)
- Jodie Stephenson
- Centre for Neuroscience and TraumaBarts and the Blizard Institute, LondonSchool of Medicine and DentistryQueen Mary University of LondonLondonUK
- Department of PathologyVU University Medical CentreAmsterdamthe Netherlands
| | - Erik Nutma
- Department of PathologyVU University Medical CentreAmsterdamthe Netherlands
| | - Paul van der Valk
- Department of PathologyVU University Medical CentreAmsterdamthe Netherlands
| | - Sandra Amor
- Centre for Neuroscience and TraumaBarts and the Blizard Institute, LondonSchool of Medicine and DentistryQueen Mary University of LondonLondonUK
- Department of PathologyVU University Medical CentreAmsterdamthe Netherlands
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17
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Altered cerebral glucose metabolism normalized in a patient with a pediatric autoimmune neuropsychiatric disorder after streptococcal infection (PANDAS)-like condition following treatment with plasmapheresis: a case report. BMC Neurol 2018; 18:60. [PMID: 29720109 PMCID: PMC5930772 DOI: 10.1186/s12883-018-1063-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 04/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background Pediatric autoimmune neuropsychiatric disorder after streptococcal infection (PANDAS) is a specific autoimmune response to group-A streptococcal infections in children and adolescents with a sudden onset of obsessive-compulsive disorders or tic-like symptoms. Cerebral metabolic changes of patients have not yet been observed. Case presentation We present a case of an 18-year old male with a PANDAS-like condition after developing tic-like symptoms and involuntary movements three weeks after cardiac surgery. The patient had suffered from pharyngotonsillitis before the symptoms started. The anti-streptolysin O (ASO) titer was elevated (805 kU/l). Antibiotic therapy did not improve his condition. Intravenous immunoglobulins and high-dose cortisone therapy had minor beneficial effects on his involuntary movements. 18F-Fluorodeoxyglucose positron emission tomography/ computer tomography (18F-FDG PET/CT) demonstrated pronounced hypermetabolism of the basal ganglia and cortical hypometabolism. The patient was treated with five cycles of plasmapheresis. A marked clinical improvement was observed after four months. Cerebral metabolic alterations had completely normalized. Conclusions This is the first report of cerebral metabolic changes observed on FDG-PET/CT in a patient with a PANDAS-like condition with a normalization following immunomodulatory treatment. Cerebral FDG-PET/CT might be a promising tool in the diagnosis of PANDAS.
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18
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Viswanathan S, Hung SKY, Goyal V, Apiwattanakul M, Thirugnanam UN, Abdullah S, Aye SMM, Ohnmar O, Si LT, Keosodsay S, Estiasari R, Khalife N, Hiew FL. Second regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders, Kuala Lumpur, Malaysia, 9th December 2017. J Clin Apher 2018; 33:559-568. [PMID: 29626354 DOI: 10.1002/jca.21630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022]
Abstract
In December 2017, 79 delegates attended the 2nd regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders in Kuala Lumpur, Malaysia. This meeting featured 6 plenary lectures, interactive sessions dedicated for experience sharing, case presentations, and a practical session for paramedics. Clinical experts and researchers from 7 SEA countries and India shared experience and challenges in treating autoimmune neurological disorders. While the spectrum of diseases and neurology practice remained largely similar, there was great disparities in accessibility of therapeutic plasma exchange (TPE) within SEA countries and between urban or rural settings. Costs, human resources, and healthcare policies are common challenges in providing sustainable TPE services. Novel techniques and innovative ideas in performing TPE were explored. A working consortium comprising of key opinion leaders was proposed to improve standards of TPE and enhance future research.
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Affiliation(s)
| | | | - Vinay Goyal
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Suhailah Abdullah
- Medical Faculty, University Melaya Medical Centre, Kuala Lumpur, Malaysia
| | | | | | - Le Tri Si
- Medical Center, Ho Chi Minh City, Vietnam
| | | | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | - Fu Liong Hiew
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
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19
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Boada M, Anaya F, Ortiz P, Olazarán J, Shua-Haim JR, Obisesan TO, Hernández I, Muñoz J, Buendia M, Alegret M, Lafuente A, Tárraga L, Núñez L, Torres M, Grifols JR, Ferrer I, Lopez OL, Páez A. Efficacy and Safety of Plasma Exchange with 5% Albumin to Modify Cerebrospinal Fluid and Plasma Amyloid-β Concentrations and Cognition Outcomes in Alzheimer's Disease Patients: A Multicenter, Randomized, Controlled Clinical Trial. J Alzheimers Dis 2018; 56:129-143. [PMID: 27911295 PMCID: PMC5240541 DOI: 10.3233/jad-160565] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Studies conducted in animal models and humans suggest the presence of a dynamic equilibrium of amyloid-β (Aβ) peptide between cerebrospinal fluid (CSF) and plasma compartments. Objective: To determine whether plasma exchange (PE) with albumin replacement was able to modify Aβ concentrations in CSF and plasma as well as to improve cognition in patients with mild-moderate Alzheimer’s disease (AD). Methods: In a multicenter, randomized, patient- and rater-blind, controlled, parallel-group, phase II study, 42 AD patients were assigned (1 : 1) to PE treatment or control (sham) groups. Treated patients received a maximum of 18 PE with 5% albumin (Albutein®, Grifols) with three different schedules: two PE/weekly (three weeks), one PE/weekly (six weeks), and one PE/bi- weekly (12 weeks), plus a six-month follow-up period. Plasma and CSF Aβ1–40 and Aβ1–42 levels, as well as cognitive, functional, and behavioral measures were determined. Results: CSF Aβ1–42 levels after the last PE compared to baseline were marginally higher in PE-treated group versus controls (adjusted means of variation: 75.3 versus –45.5 pg/mL; 95% CI: –19.8, 170.5 versus 135.1, 44.2; p = 0.072). Plasma Aβ1–42 levels were lower in the PE-treated group after each treatment period (p < 0.05). Plasma Aβ1–40 levels showed a saw-tooth pattern variation associated with PE. PE-treated patients scored better in the Boston Naming Test and Semantic Verbal Fluency (p < 0.05) throughout the study. Neuropsychiatric Inventory scores were higher in controls during the PE phase (p < 0.05). Conclusion: PE with human albumin modified CSF and plasma Aβ1–42 levels. Patients treated with PE showed improvement in memory and language functions, which persisted after PE was discontinued.
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Affiliation(s)
- Mercè Boada
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain.,Neurology Service, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Fernando Anaya
- Nephrology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Javier Olazarán
- Neurology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Joshua R Shua-Haim
- Alzheimer's Research Corporation, Mid Atlantic Geriatric Association, Manchester, NJ, USA
| | - Thomas O Obisesan
- Department of Internal Medicine, Howard University, Washington, DC, USA
| | - Isabel Hernández
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain
| | - Joan Muñoz
- Banc de Sang i Teixits, Barcelona, Spain
| | - Mar Buendia
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain
| | - Montserrat Alegret
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain
| | - Asunción Lafuente
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain
| | - Lluís Tárraga
- Memory Clinic and Research Center of Fundació ACE, Institut Catalá de Neurociències Aplicades, Barcelona, Spain
| | - Laura Núñez
- Clinical Trials Department, Instituto Grifols S.A., Barcelona, Spain
| | - Mireia Torres
- Clinical Trials Department, Instituto Grifols S.A., Barcelona, Spain
| | | | - Isidre Ferrer
- Institut de Neuropatologia, Hospital Universitario Bellvitge, Barcelona, Spain
| | - Oscar L Lopez
- Departments of Neurology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Antonio Páez
- Clinical Trials Department, Instituto Grifols S.A., Barcelona, Spain
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20
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Agarwal S, Keller JR, Nunneley CE, Muscal E, Braun MC, Srivaths P, Lotze TE. Therapeutic Plasma Exchange Use in Pediatric Neurologic Disorders at a Tertiary Care Center: A 10-Year Review. J Child Neurol 2018; 33:140-145. [PMID: 29334853 DOI: 10.1177/0883073817749368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pediatric neurologic conditions requiring therapeutic plasma exchange are rare in children and literature is sparse. The study aims to determine the outcomes, safety, and feasibility of therapeutic plasma exchange treatment in pediatric neurologic disorders. This retrospective analysis looked at the outcomes and safety of therapeutic plasma exchange in children (n = 50) with neurologic conditions. Patient age ranged <1 to 19 years old with a mean of 10.35 years. Of the 50 children treated with plasmapheresis, 26 patients received inpatient rehabilitation. At discharge, functional status can be summarized as follows: 24 (48%) with mental status impairment, 10 (20%) with vision impairment, 19 (38%) with bladder incontinence, and 37 (74%) with motor impairment. Three-month follow-up: 30% with mental status impairment, 10% with vision impairment, 18% with bladder incontinence, and 52% with motor impairment. Therapeutic plasma exchange is an effective and safe therapy for neurological conditions in the pediatric population.
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Affiliation(s)
- Sonika Agarwal
- 1 Division of Neurology & Developmental Neuroscience, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | | | - Eyal Muscal
- 1 Division of Neurology & Developmental Neuroscience, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.,3 Division of Immunology, Allergy And Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael C Braun
- 4 Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Poyyapakkam Srivaths
- 4 Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Timothy E Lotze
- 1 Division of Neurology & Developmental Neuroscience, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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21
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22
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Hau Man TH, Shek-Kwan CR, On-Kei CA, Lam CPW. Effect of plasmapheresis on serum levels of clobazam, levetiracetam and topiramate. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 8:66-68. [PMID: 28951835 PMCID: PMC5607118 DOI: 10.1016/j.ebcr.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/05/2017] [Accepted: 07/13/2017] [Indexed: 11/12/2022]
Abstract
A 27-year-old man with a diagnosis of new onset refractory status epilepticus (NORSE) was treated with five anti-seizure drugs (ASDs) including clobazam, levetiracetam and topiramate. He received plasma exchange (PE) for presumed autoimmune etiology. Serum ASD levels were serially monitored in two sessions. Levels of clobazam, levetiracetam and topiramate were significant reduced by PE. Serum clobazam level dropped down to at least 85% and 75% of the baseline during and after the procedure respectively; levetiracetam dropped down to 83% and 83%; and topiramate dropped to 86% and 79%. The results may imply a theoretical risk of breakthrough seizure during PE due to low ASD levels. Plasmapheresis is shown to cause significant decrease in serum levels of clobazam, levetiracetam and topiramate. There is a theoretical risk of seizures in the period around plasmapheresis due to fluctuation in the serum level of the antiseizure drug. Plasmapheresis may have a role in management of antiseizure drug toxicity.
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Affiliation(s)
| | | | - Chan Angel On-Kei
- Division of Clinical Biochemistry, Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong
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23
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Ortiz-Salas P, Velez-Van-Meerbeke A, Galvis-Gomez CA, Rodriguez Q JH. Human Immunoglobulin Versus Plasmapheresis in Guillain-Barre Syndrome and Myasthenia Gravis: A Meta-Analysis. J Clin Neuromuscul Dis 2016; 18:1-11. [PMID: 27552383 DOI: 10.1097/cnd.0000000000000119] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety over a short time period of human intravenous immunoglobulin versus plasma exchange (PE) in the management of some autoimmune neurologic diseases. In addition, length of hospital stay and duration of ventilator support were compared. METHODS Randomized controlled trials and analytical observational studies of more than 10 cases were reviewed. Cochrane Neuromuscular Disease Group trials, MEDLINE, EMBASE, HINARI, and Ovid, were searched as data source. Reference lists were examined for further relevant articles. A random-effect model was used to derive a pooled risk ratio. RESULTS A total of 552 articles were found and 24 met the criteria for a studied population of 4657 cases: 14 articles were about Guillain-Barré syndrome and 10 of myasthenia gravis. No evidence was found to suggest that PE or intravenous immunoglobulin differed in terms of efficacy or safety to treat any of the 2 diseases. Hospital stay length and ventilatory support time are different in each illness; however, we found no statistical difference in either of the 2 treatments. CONCLUSIONS There is no evidence for superiority in the efficacy or safety of immunoglobulin or plasmapheresis in the management of Guillain-Barré syndrome and myasthenia gravis. However, caution should be exercised in the interpretation of these results given the limitations in the quality of the evidence and the heterogeneity of the studies.
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Affiliation(s)
- Paola Ortiz-Salas
- *Department of Neurology Fundación Cardioinfantil-Instituto de Cardiología, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia; †Neuroscience (neURos) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia; ‡School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia; and §Department of Neurology Fundación Cardioinfantil-Instituto de Cardiología, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
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THE USE OF PLASMAPHERESIS IN TREATMENT OF PATIENTS WITH INFERTILITY, PERITONEAL ENDOMETRIOSIS AND NAT2 GENE POLYMORPHISM. EUREKA: HEALTH SCIENCES 2016. [DOI: 10.21303/2504-5679.2016.00087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
It is known that 30–40 % of patients with peritoneal endometriosis suffer from infertility. Half of the patients with endometriosis are identified point mutation in NAT2 – gene, which plays an important role in the acetylation of aromatic and heterocyclic amines, in the accumulation of endotoxins, activation of free radical oxidation, impaired microcirculation. These factors involve the use of methods of gemapheresis which have detoxification, the blood rheology corrective and immune corrective effects.
The purpose of this study was to evaluate the efficacy of therapeutic plasma exchange in treatment of patients with peritoneal form of endometriosis, infertility and point mutations in the gene NAT2.
The study included 140 patients with infertility, peritoneal form of endometriosis and point mutations in the gene NAT2. All patients are performed laparoscopy, coagulation foci of endometriosis. In the following 93 (66.4 %) patients were treated with a the course of therapeutic plasmapheresis using the apparatus «PCS-2» with the removal of 20–25 % the volume of circulating plasma with replacement plasma of crystalloid and colloid solutions. Before treatment were shown the signs of endotoxemia, activation of oxidative stress. After treatment with the use of plasmapheresis was revealed the significant reduction of endogenous intoxication parameters and oxidative stress. Also is noted the increase in the pregnancy rate, both independently and in IVF programs, especially during the first 3 months after treatment. The findings suggest that the efficiency of the proposed comprehensive treatment techniques (laparoscopy and subsequent course of therapeutic plasmapheresis) of patients with peritoneal endometriosis and infertility and with point mutations in the gene NAT2. The use of plasmapheresis is pathogenetically justified in patients of the studied group.
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Mühlhausen J, Kitze B, Huppke P, Müller GA, Koziolek MJ. Apheresis in treatment of acute inflammatory demyelinating disorders. ATHEROSCLEROSIS SUPP 2015; 18:251-6. [DOI: 10.1016/j.atherosclerosissup.2015.02.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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26
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Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res 2014; 1617:144-54. [PMID: 25301689 DOI: 10.1016/j.brainres.2014.09.071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/29/2022]
Abstract
Infections, and the resulting immune response to these infections, have recently received increased recognition as pathogenic mechanisms for neuropsychiatric disorders. Sydenham's chorea (SC), a widely recognized post-streptococcal autoimmune disorder, represents a model for this proposed pathogenesis. In SC, a dysregulated immune response to a streptococcal infection is hypothesized to result in inflammation of neuronal networks, particularly the basal ganglia nuclei. The resulting dysfunction in the basal ganglia nuclei are hypothesized to lead to a constellation of adventitious movements and psychiatric symptoms, which investigations have shown are amenable to immunomodulatory therapies. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections) has been proposed as a variant of SC, and is hypothesized to share a pathogenic mechanism, despite a unique symptom profile of predominantly psychiatric symptoms. In this review, we present the clinical aspects of both disorders, the data for potential shared etiopathogenesis between them, and the evidence for the therapeutic use of immunomodulatory therapies for the symptoms of SC and PANDAS. This article is part of a Special Issue entitled SI: Neuroimmunology in Health And Disease.
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Affiliation(s)
- Kyle A Williams
- Pediatric Neuropsychiatry and Immunology Clinic, Department of Psychiatry, Massachusetts General Hospital, MA, United States; Department of Psychiatry, Harvard Medical School, MA 02114, United States.
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, MA, United States
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Treatment of chronic inflammatory demyelinating polyneuropathy: from molecular bases to practical considerations. Autoimmune Dis 2014; 2014:201657. [PMID: 24527207 PMCID: PMC3914592 DOI: 10.1155/2014/201657] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/13/2013] [Indexed: 02/07/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease of the peripheral nervous system, in which both cellular and humoral immune responses are involved. The disease is clinically heterogeneous with some patients displaying pure motor form and others also showing a variable degree of sensory dysfunction; disease evolution may also differ from patient to patient, since monophasic, progressive, and relapsing forms are reported. Underlying such clinical variability there is probably a broad spectrum of molecular dysfunctions that are and will be the target of therapeutic strategies. In this review we first explore the biological bases of current treatments and subsequently we focus on the practical management that must also take into account pharmacoeconomic issues.
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