Hyperviscosity syndrome associated with an idiopathic monoclonal IgA-rheumatoid factor

National Survey of Hemapheresis Practice in Hungary 2001?2004

In the current study, the authors evaluated data provided by Hungarian hemapheresis centers to the National Health Insurance (NHI) organization between 2001 and 2004 with the intention of having costs reimbursed. The primary objective of the present study was to rank data by frequency of indications of therapeutic plasma exchange (TPE). Furthermore, we compared frequency data with the Canadian TPE Registry and reviewed medical evidence regarding the adequacy of applying TPE at chosen indications based on data in literature. It was concluded that the number of TPEs (and thus the reimbursed costs) increased steadily year by year. It is worth considering the difference between the five most frequent indications of TPE in Hungary or in Canada. Clinicians tend to apply TPE in many cases as a last resort treatment of many diseases unresponsive to conventional therapy. Consequently, there are many illnesses for which the value of TPE is still questionable (or unproven) and its use is considered investigational or experimental. Nevertheless, cumulative medical experience does not always confirm the adequacy of TPE in all treatments, retrospectively. Thus, limited financial resources oblige clinicians to be judicious in providing apheresis services.

Hyperviscosity syndrome

Hyperviscosity syndrome is clinically manifested by oronasal bleeding, retinal hemorrhages, and variable neurological symptoms. It occurs when resistance to flow of blood increases sharply, resulting in impaired transit through the microcirculatory system. The most common cause of hyperviscosity is increased concentrations of gamma globulins, either monoclonal in malignant disease or polyclonal, usually seen with rheumatic disorders. Increased numbers of red blood cells, as in polycythemia vera, can result in viscous blood. Extreme increases in concentrations of mature and immature white blood cells can also produce hyperviscosity. Treatment with plasma exchange is required when the clinical syndrome is symptomatic. Although plasma exchange is not a completely benign procedure, it represents the most effective method of controlling hyperviscosity.

Selective bone marrow involvement of lymphoplasmacytic cells secreting monoclonal IgA rheumatoid factor in a patient with Sjögren's syndrome and serum hyperviscosity

The clinical features and results of serological studies of a patient with Sjögren's syndrome, IgA kappa monoclonal gammopathy, and hyperviscosity syndrome are reported. The novel aspect of this case is the selective localisation to the bone marrow of lymphoplasmacytoid cells secreting IgA kappa morphologically identical to the cells infiltrating the salivary glands. The serum of the patient contained large amounts of immunoglobulin-anti-immunoglobulin immune complexes. By gel filtration chromatography it was shown that the immune complexes formed a peak of molecular weight 680 kilodaltons. The immune complexes were dissociable under acidic conditions. The immunoglobulin with rheumatoid activity was characterised as monoclonal IgA kappa protein. Treatment with plasmapheresis combined with immunosuppressive treatment with cyclophosphamide reduced the serum viscosity with concomitant clinical improvement.

Rheology of paraproteinaemias and the plasma hyperviscosity syndrome

The proper understanding of the causes, pathophysiology, diagnosis and management of the plasma hyperviscosity syndrome is based on good knowledge of malignant paraproteinaemias, properties of immunoglobulins, rheology of blood in the microcirculation, and modern plasma separation techniques. This multifaceted syndrome complicates less than ten per cent of IgA and IgG myelomas, and up to one-third of Waldenström's macroglobulinaemias. A few cases of HVS have also been reported in association with polyclonal hypergammaglobulinaemias. Excessive paraproteinaemia may cause the plasma HVS, especially when paraproteins are extraordinarily large, asymmetrical or cryosensitive, or if they aggregate into hyperviscous macroaggregates. The resultant severe microcirculatory impairment is mainly due to the combined effects of plasma hyperviscosity, significant plasma volume expansion and intense red cell aggregation. The individually variable general symptoms, bleeding tendency, ocular, neurological, cardiovascular, and renal manifestations and laboratory parameters of the HVS are summarized briefly. The majority of patients present hyperviscosity manifestations when the plasma viscosity exceeds 5-6 mPa.s. Plasmapheresis or plasma exchange have established themselves as efficient and safe modes of therapy of hyperviscosity and hypervolaemia. The therapeutic guidelines for the plasma HVS are briefly discussed with regard to recent experience with developing plasma separation techniques. Diagnostic and therapeutic advances combined with increasing haemorheological knowledge have greatly improved the proper management of this potentially lethal complication of paraproteinaemias.

Pulmonary hypertension secondary to serum hyperviscosity in a patient with rheumatoid arthritis

A patient with rheumatoid arthritis who was evaluated for dyspnea of six months' duration is described. Although no primary cardiac or parenchymal lung disease was identified, right heart catheterization revealed marked pulmonary hypertension. The patient was presumed to have pulmonary arteritis. Evaluation of her hyperproteinemia, however, led to the discovery of a polyclonal gammopathy with a marked increase in plasma viscosity. Although the classic clinical findings of the hyperviscosity syndrome were minimal, the patient underwent plasmapheresis, resulting in a marked reduction of pulmonary artery pressures (from 53 +/- 4 mm Hg, mean +/- SD, to 30 +/- 3 mm Hg, p less than 0.05) and pulmonary vascular resistance (from 707 +/- 63 dynes/second/cm5 to 421 +/- 72 dynes/second/cm5, p less than 0.05) concomitant with a return to normal plasma viscosity. Her dyspnea completely resolved. This represents the first successful treatment of pulmonary hypertension by plasmapheresis. Protein evaluation revealed the presence of intermediate complexes of IgG rheumatoid factor. The hyperviscosity syndrome should be considered in the differential diagnosis of pulmonary hypertension in patients with rheumatoid arthritis and other disorders associated with a polyclonal or monoclonal gammopathy. Pulmonary hypertension secondary to the hyperviscosity syndrome is reversible by plasmapheresis. Immunosuppressive therapy that reduces immunoglobulin production may provide a means of long-term treatment.

Induction of neutrophil enzyme release by rheumatoid factors: evidence for differences based on molecular characteristics

Cathepsin G and elastase are two neutrophil proteases capable of degrading the major structural macromolecules of the joint. Evaluation of factors capable of inducing the release of these enzymes is crucial to the understanding of neutrophil-mediated tissue destruction. We have evaluated the effects of IgM rheumatoid factor (RF), as well as monomeric and polymeric forms of IgA RF, on the release of neutrophil elastase, cathepsin G, and the specific granule protein lactoferrin. None of these rheumatoid factors alone was able to induce more lysosomal protein release than media controls. Under conditions used in this study, aggregated human IgG was able to induce slightly more release than media controls. The addition of IgM RF or polymeric IgA RF to the aggregated IgG resulted in release of significantly more lysosomal proteins than aggregates alone. In contrast, monomeric IgA RF, even in the presence of aggregated IgG, was unable to augment enzyme release. These results suggest that differences in the molecular characteristics of RF found in synovial fluid may significantly influence the contribution of RF to tissue injury in rheumatoid arthritis.

IgA rheumatoid factor synthesis by dissociated synovial cells. Characterization and relationship to IgM rheumatoid factor synthesis

We examined patterns of IgA rheumatoid factor (RF) and IgM-RF synthesis by dissociated synovial cells obtained from 27 patients with seropositive rheumatoid arthritis. Synthesis of IgA-RF was observed in 19 of 34 synovial cell preparations from these patients and constituted a mean of 16% of the total IgA produced. IgA-RF expression correlated only weakly with IgM-RF production (r = 0.385) and could be dissociated from production of IgA-RF (and IgM-RF) exhibited by simultaneously obtained peripheral blood plasma cells. While wide variations were observed in the ratio of IgA-RF:IgM-RF produced by synovial B cells in the patient sample studied, remarkable consistency in the relationship of IgA-RF to IgM-RF synthesis was observed over time in different joints of the same patient. IgA-RF synthesized by dissociated synovial cells was predominantly of the IgA1 subclass and existed in both monomeric and polymeric forms. Our results are compatible with the view that local production of IgA-RF and IgM-RF are regulated independently of each other.

Evaluation of hyperviscosity in monoclonal gammopathies

The serum or plasma hyperviscosity syndrome has been described in both monoclonal and polyclonal immunoglobulin disorders. The usefulness of initial and serial plasma viscosity measurements by an automated viscometer technique was evaluated and compared with serum protein electrophoresis data in 107 patients without monoclonal gammopathies and 153 patients with monoclonal gammopathies. In patients without monoclonal gammopathies, plasma viscosity correlated best with the concentration of gamma globulins. In patients with monoclonal gammopathies, plasma viscosity correlated best with the serum monoclonal protein concentration, but individual patient variations in the ratio of plasma viscosity to monoclonal protein concentration made accurate prediction of plasma viscosity difficult without direct measurement. Six of eight patients with plasma viscosity above 5.0 cp had classic symptoms of hyperviscosity syndrome, and four of the six had recurrent episodes. Six other patients with plasma viscosity above 4.0 cp had more subtle presentations of hyperviscosity but responded equally well to therapeutic lowering of plasma viscosity. These patients are part of a larger subset of 27 patients in whom initial plasma viscosity was above 3.0 cp. No patient with an initial plasma viscosity below 3.0 cp subsequently showed hyperviscosity symptoms. Plasma viscosity measured by this technique is a useful tool in screening patients with dysproteinemias to identify and monitor those with and at risk for the hyperviscosity syndrome.

Aphresis

Therapeutic apheresis is a relatively new modality. Its absolute indications are few and include hyperviscosity syndrome, cryoglobulinemia, thrombotic thrombocytopenic purpura, Goodpasture's syndrome, and life-threatening complications of immunologic disorders refractory to conventional management. The use of apheresis in most of the other disorders discussed in this monograph is experimental and should not be employed unless all the mitigating therapeutic considerations clearly suggest an overwhelming advantage of apheresis. The promise of apheresis is much greater than its current use, and the research applications of specific component separation and antibody removal are of great importance. It is hoped that these new developments will shortly make current devices obsolete and improve the clinical management of patients as well as increase our knowledge of disease etiopathogenesis.

Plasmapheresis versus lymphoplasmapheresis in rheumatoid arthritis: immunologic comparisons and literature review

Eight patients with Functional Class III, seropositive, erosive rheumatoid arthritis unresponsive to remittive drugs each underwent nine aphereses over 3 weeks. Four had a 40-ml/kg plasma exchange and four others had a 40-ml/kg plasma exchange plus a mean 5.67 X 10(9) lymphocyte depletion. Both groups appeared to improve clinically. T and B cell counts and OK T4 and OK T8 ratios decreased in the lymphoplasmapheresis group. Phytohemagglutinin stimulation decreased in lymphoplasmapheresis and increased in plasmapheresis patients with significant comparisons (p = 0.02). These findings confirm and extend previous work. Plasmapheresis and lymphoplasmapheresis appear to have fundamentally different actions on lymphocyte function.

Therapeutic apheresis. Applications and future directions

The past 10-15 years have been witness to major technological achievements in the field of therapeutic apheresis. Concurrently, a large number of diseases, primarily with an immunological basis, have been treated with apheresis. In this paper, we review the various applications of therapeutic apheresis, adverse reactions associated with the mode of therapy, and future research directions. Several representative diseases are also discussed in detail.

A quantitative assay for IgA rheumatoid factor

We developed a solid-phase radioimmunoassay capable of detecting nanogram quantities of human IgA rheumatoid factor (RF) in biological fluids. Human IgM RF, IgG RF, IgG, IgA, IgM and whole serum did not significantly interfere with the IgA RF assay. Patients with sero-positive rheumatoid arthritis (RA) had significantly higher concentrations of IgA RF than sero-negative RA patients or healthy adult controls. Concentrations of IgA RF in paired sera and synovial fluids from sero-positive RA patients were comparable. Levels of IgA RF demonstrated a moderately good correlation with levels of IgM RF in sero-positive RA sera (r = 0.673). However, the ratio of IgA RF concentration to IgM RF concentration in sero-positive RA sera varied widely.

Current status of therapeutic apheresis in rheumatoid arthritis

Evidence developed over the years has suggested that lymphocyte depletion and removal of plasma factors can ameliorate rheumatoid arthritis. In our studies of 40 patients, a subset of patients that respond best to 20 therapeutic lymphoplasmapheresis over 11 weeks has emerged. These are functional Class III patients with seropositive, erosive progressive disease who have little deformity. They must be on long-acting agents or cytotoxic drugs during pheresis to prevent antibody rebound. Other studies have since confirmed our work. The major side effects of pheresis are elucidated. Technologic developments will enable selective pheresis procedures to be in widespread use within a few years.