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Knapp S, Bolko L, Servettaz A, Didier K. [[Eosinophilic fasciitis: From pathophysiology to therapeutics]]. Rev Med Interne 2024:S0248-8663(24)00086-9. [PMID: 38519306 DOI: 10.1016/j.revmed.2024.03.006] [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: 11/23/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disorder characterized by painful edema and induration of the limbs and trunk, likely associated with hypereosinophilia and hypergammaglobulinemia. EF causes arthralgia and range of motion limitation, leading to significant functional impairment and poor quality of life. Since its description by Shulman in 1974, over 300 cases have been reported. We present here a review of the latest diagnostic, pathophysiological and therapeutic developments in this disease. Magnetic resonance imaging appears useful to guide diagnosis and biopsy. Diagnosis is based on a deep skin biopsy involving the fascia, which will reveal edema, sclerofibrosis of the muscular fascia and subcutaneous tissue, and an inflammatory infiltrate sometimes composed of eosinophilic polynuclear cells. EF may occur in patients treated with immune checkpoint inhibitors and the diagnosis should be raised in case of cutaneous sclerosis in these patients. The pathophysiology of the disease remains poorly understood, and its management lacks randomized, controlled, blinded trials. First-line treatment consists in oral corticosteroid therapy, sometimes combined with an immunosuppressant, mainly methotrexate. A better understanding of the pathophysiology has opened new therapeutic perspectives and clarified the role of targeted therapies in the management of EF, such as interleukin-6 inhibitors, whose efficacy has been reported in several cases.
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Affiliation(s)
- S Knapp
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France
| | - L Bolko
- Service de rhumatologie, hôpital Maison Blanche, CHU de Reims, Reims, France
| | - A Servettaz
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France
| | - K Didier
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France.
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2
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Jacobs JW, Adkins BD, Bibb LA, Woo JS, Allen ES, Stephens LD, Binns TC, Bloch EM, Booth GS. The potential association between extracorporeal photopheresis and thrombosis. Bone Marrow Transplant 2024; 59:270-273. [PMID: 37996561 DOI: 10.1038/s41409-023-02153-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lorin A Bibb
- Department of Dermatology, Mayo Clinic, Rocester, MN, USA
| | - Jennifer S Woo
- Department of Pathology, City of Hope National Medical Center, Irvine, CA, USA
| | - Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Laura D Stephens
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Thomas C Binns
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Garrett S Booth
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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3
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Budde H, Mohr L, Bogeski I, Riggert J, Legler TJ. Extracorporeal photopheresis and the cellular mechanisms: Effects of 8-methoxypsoralen and UVA treatment on red blood cells, platelets and reactive oxygen species. Vox Sang 2023; 118:775-782. [PMID: 37401421 DOI: 10.1111/vox.13489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal photopheresis (ECP) is a widespread cellular therapy for graft-versus-host disease, autoimmune diseases and Sézary disease. One of the main effects of ECP is the apoptosis of leukocytes, but the therapeutic mechanisms are not completely known. The aim of this study was to investigate the effects on red blood cells, platelets and the induction of reactive oxygen species. MATERIALS AND METHODS We used human cells from healthy blood donors to simulate in vitro the composition in an apheresis bag. Cells were treated with 8-methoxypsoralen (8-MOP) and UVA. Red blood cell stability, platelet activity and induction of reactive oxygen species were analysed. RESULTS After 8-MOP and UVA treatment, the red blood cells showed high cell integrity with low levels of eryptosis and no increase of free haemoglobin or red blood cell distribution width (RDW). Red blood cell immune-associated antigens CD59 and CD147 were hardly affected by the treatment. Platelet glycoproteins CD41, CD62P and CD63 indicated strong platelet activation after 8-MOP and UVA treatment. Reactive oxygen species were slightly but not significantly induced by the treatment. CONCLUSION The effect of the ECP therapy is probably not exclusively mediated by leukocytes. Platelet activation is another striking effect caused by the treatment of the apheresis product with 8-MOP/UVA. However, since we could hardly identify any evidence for eryptosis or haemolysis, it is unlikely that red blood cell eryptosis is part of the therapeutic mechanism. Further research on this topic seems to be promising.
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Affiliation(s)
- Holger Budde
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Lea Mohr
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Ivan Bogeski
- Molecular Physiology Division, Institute of Cardiovascular Physiology, University Medical Center Göttingen, Göttingen, Germany
| | - Joachim Riggert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias J Legler
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
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Hähnel V, Brosig AM, Ehrenschwender M, Burkhardt R, Offner R, Ahrens N. Apoptosis induction by extracorporeal photopheresis is enhanced by increasing the 8-methoxypsoralen concentration and by replacing plasma with saline. Transfusion 2021; 61:2991-2999. [PMID: 34427336 DOI: 10.1111/trf.16634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP), an apheresis-based therapy for various immunological diseases, works mainly by inducing apoptosis in lymphocytes. Several factors influence the efficacy of ECP with the photosensitizer 8-methoxypsoralen (8-MOP) and ultraviolet light A (UVA). This study aimed to optimize treatment by varying the 8-MOP starting concentration and the cell suspension medium. MATERIALS AND METHODS All patients (n = 13) included in this study received photopheresis as medically indicated. Cells collected with a Spectra Optia apheresis system were suspended in plasma or physiological saline (NaCl) and incubated with 200 ng/ml versus 340 ng/ml photosensitizer before UVA irradiation (Macogenic G2 or UVA PIT system). Lymphocyte apoptosis and caspase activity were analyzed by flow cytometry and fluorimetry, and residual 8-methoxypsoralen concentrations by liquid chromatography-mass spectrometry. RESULTS Raising the 8-MOP starting concentration significantly increased lymphocyte apoptosis, with values of 22% versus 35% (plasma) and 28%-46% (NaCl) at 24 h post-ECP and 37% versus 86% (plasma) and 74% versus 97% (NaCl) at 48 h for 200 ng/ml versus 340 ng/ml. Pre-transfusion residual 8-MOP levels were 168 ng/ml (plasma) and 162 ng/ml (NaCl) versus 290 ng/ml (plasma) and 266 ng/ml (NaCl) for the lower versus higher dose, respectively. DISCUSSION Hence, 8-MOP concentration influences the efficacy of photopheresis as lymphocyte apoptosis rates were significantly higher with the higher starting concentration and with NaCl versus plasma. This indicates that increased 8-MOP starting doses and saline as additional suspension medium could help in improving ECP's efficacy.
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Affiliation(s)
- Viola Hähnel
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Andreas-Michael Brosig
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Martin Ehrenschwender
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Ahrens
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany.,MVZ for Laboratory Diagnostics, amedes, Raubling, Germany
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Esme P, Coban SN, Ugur B, Aylı M, Caliskan E. A case of psoriasis successfully treated by extracorporeal photopheresis during COVID-19 pandemic. Transfus Apher Sci 2021; 60:103200. [PMID: 34215520 PMCID: PMC8234246 DOI: 10.1016/j.transci.2021.103200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
Psoriasis is a chronic inflammatory skin disease that is characterized by well-demarcated erythematous plaques with a silver scale. Although many new and emerging therapeutic agents are often sufficient to control the disease, there is still a need for alternative treatment options in challenging cases. Extracorporeal photopheresis (ECP) has been applied to many T-cell-mediated diseases to restore immune homeostasis and treat psoriasis effectively. In this paper, we present a psoriasis patient who did not respond to methotrexate, narrowband ultraviolet B, or acitretin. Because of a diagnosis of non-Hodgkin lymphoma, the patient had contraindications for cyclosporine, fumaric acid esters, and biologics but achieved remission with a total of 12 sessions of ECP in two and a half months. Although exacerbation was recorded after polymerase chain reaction (PCR) confirmed coronavirus 2019 (COVID-19) disease infection at the end of the first month, scores from the psoriasis area severity index (PASI) and dermatological life quality index (DLQI) were regressed significantly within two and a half months. ECP seems to provide an effective and rapid response for psoriasis and should be considered for psoriasis patients who fail to respond or have contraindications to existing treatments.
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Affiliation(s)
- Pelin Esme
- Departments of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Sema Nur Coban
- Departments of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Bilge Ugur
- Departments of Hematology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Meltem Aylı
- Departments of Hematology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Ercan Caliskan
- Departments of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey.
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Hähnel V, Weber I, Tuemmler S, Graf B, Gruber M, Burkhardt R, Ahrens N. Matrix-dependent absorption of 8-methoxypsoralen in extracorporeal photopheresis. Photochem Photobiol Sci 2020; 19:1099-1103. [PMID: 32638713 DOI: 10.1039/c9pp00378a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an effective immunomodulatory therapy for various diseases. Autologous leukocytes are collected, photoactivated with a photosensitizer (8-methoxypsoralen, 8-MOP) and UVA light, and subsequently reinfused back to the patient. Leukapheresis and UVA irradiation systems can be integrated into one device (inline) or handled by two separate devices (offline). ECP works via intercalation of 8-MOP into DNA helices and UVA-based interactions to inhibit DNA replication. 8-MOP is known to adhere to plastic materials, which might reduce its availability for intercalation. In the present study we examined the bioavailability of 8-MOP when different plastic materials and solvents are used as matrices. METHODS Varying amounts of shredded ethylene vinyl acetate (EVA) and polyvinylchloride (PVC) from the MacoGenic irradiation bag (EVA1), UVA PIT irradiation bag (EVA2), UVA PIT recirculation bag (PVC A) and UVA PIT tubing (PVC B) by MacoPharma and PIT Medical Systems, respectively, were incubated with 200 ng mL-1 8-MOP dissolved in diisopropyl ether (DIPE) plus toluene 90/10 vol%, deionized water or plasma. After 2 h 8-MOP concentrations were determined by GC-MS. RESULTS After incubation, 8-MOP concentrations varied depending on the amount and type of plastic (PVC > EVA) and solvent (water > plasma > DIPE/toluene). Absorption to 200 mg EVA1 or EVA2 resulted in 8-MOP concentrations of 57% or 32% in water, 91% or 80% in plasma, and 93% or 92% in DIPE/toluene, while 200 mg PVC A and PVC B yielded recovery rates of 26% and 10% in water, 76% and 75% in plasma, and 55% and 30% in DIPE/toluene, respectively. Remaining 8-MOP differed significantly between container materials (EVA vs. PVC; p < 0.022) but not manufacturers (MacoPharma vs. PIT Medical Systems). CONCLUSION Absorption loss of 8-MOP depends on the type of plastic and solvent and is more pronounced with water than with plasma. As the DNA binding effect of 8-MOP is dose-dependent, ECP starting doses should be adjusted to ensure that a sufficient concentration of free bioavailable 8-MOP is present during UV irradiation.
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Affiliation(s)
- Viola Hähnel
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Isabell Weber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Simon Tuemmler
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany.
| | - Ralph Burkhardt
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Ahrens
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 766] [Impact Index Per Article: 153.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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8
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Coppard C, Bonnefoy F, Hannani D, Gabert F, Manches O, Plumas J, Perruche S, Chaperot L. Photopheresis efficacy in the treatment of rheumatoid arthritis: a pre-clinical proof of concept. J Transl Med 2019; 17:312. [PMID: 31533744 PMCID: PMC6751641 DOI: 10.1186/s12967-019-2066-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/10/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite major advances in rheumatoid arthritis outcome, not all patients achieve remission, and there is still an unmet need for new therapeutic approaches. This study aimed at evaluating in a pre-clinical murine model the efficacy of extracorporeal photopheresis (ECP) in the treatment of rheumatoid arthritis, and to provide a relevant study model for dissecting ECP mechanism of action in autoimmune diseases. METHODS DBA/1 mice were immunized by subcutaneous injection of bovine collagen type II, in order to initiate the development of collagen-induced arthritis (CIA). Arthritic mice received 3 ECP treatments every other day, with psoralen + UVA-treated (PUVA) spleen cells obtained from arthritic mice. Arthritis score was measured, and immune cell subsets were monitored. RESULTS ECP-treated mice recovered from arthritis as evidenced by a decreasing arthritic score over time. Significant decrease in the frequency of Th17 cells in the spleen of treated mice was observed. Interestingly, while PUVA-treated spleen cells from healthy mouse had no effect, PUVA-treated arthritic mouse derived-spleen cells were able to induce control of arthritis development. CONCLUSIONS Our results demonstrate that ECP can control arthritis in CIA-mice, and clarifies ECP mechanisms of action, showing ECP efficacy and Th17 decrease only when arthritogenic T cells are contained within the treated sample. These data represent a pre-clinical proof of concept supporting the use of ECP in the treatment of RA in Human.
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Affiliation(s)
- Céline Coppard
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France
| | - Francis Bonnefoy
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098 RIGHT, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, 25000, Besançon, France
| | - Dalil Hannani
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France.,CNRS, CHU Grenoble, Grenoble INP, TIMC-IMAG, UMR 5525, Université Grenoble Alpes, 38000, Grenoble, France
| | - Françoise Gabert
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France
| | - Olivier Manches
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France
| | - Joel Plumas
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France
| | - Sylvain Perruche
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098 RIGHT, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, 25000, Besançon, France
| | - Laurence Chaperot
- Institute for Advanced Biosciences, Université Grenoble Alpes, Inserm U 1209, CNRS, UMR 5309, 38000, Grenoble, France. .,Etablissement Français du Sang Auvergne-Rhône-Alpes, Research and Development Lab, 29 Av Maquis du Grésivaudan, 38701, La Tronche, France.
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Du AX, Osman M, Gniadecki R. Use of Extracorporeal Photopheresis in Scleroderma: A Review. Dermatology 2019; 236:105-110. [PMID: 31362294 DOI: 10.1159/000501591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Scleroderma is a heterogeneous group of diseases that can be localized or systemic. Localized scleroderma is a fibrosis of the skin characterized by inflammation and thickening due to excessive collagen deposition, and systemic sclerosis (SSc) is characterized by vasculopathy, immune dysregulation and skin fibrosis. In general, the prognosis of scleroderma highly depends on the degree of visceral involvement and relates to the degree of skin fibrosis. Despite the numerous therapies used for patients with scleroderma, the disease-related morbidity and mortality are high. Studies have explored the effects of extracorporeal photopheresis (ECP) in scleroderma treatment. Originally used in the treatment of cutaneous T-cell lymphoma, ECP is an immunomodulatory procedure in which a patient's white blood cells are treated with 8-methoxypsoralen and exposed to UVA radiation to inhibit cell proliferation and induce immunosuppression. SUMMARY Multiple lines of evidence suggest that ECP may be a safe and possibly effective therapy for patients with scleroderma, specifically demonstrating improvement in patients with cutaneous manifestations of the disease. However, future studies assessing its role in managing visceral involvement are needed. Our review aims to examine and consolidate the results of clinical studies and propose a possible role for ECP in the management of scleroderma. KEY POINTS ECP may be an effective and safe procedure for the treatment of SSc.
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Affiliation(s)
- Amy X Du
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed Osman
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Gniadecki
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada, .,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, .,Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada,
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10
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Santi CG, Gripp AC, Roselino AM, Mello DS, Gordilho JO, Marsillac PFD, Porro AM. Consensus on the treatment of autoimmune bullous dermatoses: bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa acquisita - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:33-47. [PMID: 31166405 PMCID: PMC6544032 DOI: 10.1590/abd1806-4841.2019940207] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/30/2019] [Indexed: 02/06/2023] Open
Abstract
Bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa
acquisita are subepidermal autoimmune blistering diseases whose antigenic target
is located at the basement membrane zone. Mucous membrane pemphigoid and
epidermolysis bullosa acquisita can evolve with cicatricial mucosal involvement,
leading to respiratory, ocular and/or digestive sequelae with important
morbidity. For each of these dermatoses, a literature review covering all
therapeutic options was performed. A flowchart, based on the experience and
joint discussion among the authors of this consensus, was constructed to provide
treatment orientation for these diseases in Brazil. In summary, in the
localized, low-risk or non-severe forms, drugs that have immunomodulatory action
such as dapsone, doxycycline among others may be a therapeutic option. Topical
treatment with corticosteroids or immunomodulators may also be used. Systemic
corticosteroid therapy continues to be the treatment of choice for severe forms,
especially those involving ocular, laryngeal-pharyngeal and/or esophageal
mucosal involvement, as may occur in mucous membrane pemphigoid and
epidermolysis bullosa acquisita. Several immunosuppressants are used as adjuvant
alternatives. In severe and recalcitrant cases, intravenous immunoglobulin is an
alternative that, while expensive, may be used. Immunobiological drugs such as
rituximab are promising drugs in this area. Omalizumab has been used in bullous
pemphigoid.
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Affiliation(s)
- Claudia Giuli Santi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Carlos Gripp
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Ana Maria Roselino
- Department of Medical Clinics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Danielle Santana Mello
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Paula Figueiredo de Marsillac
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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11
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Partarrieu-Mejías F, Giacaman-Von der Weth MM, Pérez-Ferriols A, Goterris-Viciedo R, Alegre-de Miquel V. Steroid-resistant eosinophilic fasciitis successfully treated with addition of extracorporeal photopheresis. Dermatol Ther 2019; 32:e12926. [PMID: 31025428 DOI: 10.1111/dth.12926] [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: 03/02/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
Eosinophilic fasciitis (EF) is an uncommon fibrosing disease of the fascia with characteristic cutaneous and hematologic manifestations. Although EF is most commonly treated with corticosteroids at the beginning, a considerable number of patients show an inadequate response and hence various therapeutic strategies have been tried, including extracorporeal photopheresis (ECP). We describe the case of a 66-year-old woman with steroid-resistant EF that improved significantly after ECP was added to her treatment regimen. To date, only six cases of this therapeutic strategy have been reported in English literature.
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Affiliation(s)
| | | | | | - Rosa Goterris-Viciedo
- Hematology and Hemotherapy Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
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12
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Coppard C, Hannani D, Humbert M, Gauthier V, Plumas J, Merlin E, Gabert F, Chaperot L. In vitro PUVA treatment triggers calreticulin exposition and HMGB1 release by dying T lymphocytes in GVHD: New insights in extracorporeal photopheresis. J Clin Apher 2019; 34:450-460. [PMID: 30860623 DOI: 10.1002/jca.21698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/23/2019] [Accepted: 02/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an effective therapy for graft vs host disease (GVHD), based on infusion of UVA-irradiated and 8 methoxy-psoralen (PUVA)-treated leukocytes. Reinfusion of these apoptosing cells affects the functionality of pathogenic T cells through poorly understood immunomodulatory mechanisms. Apoptosis is usually a silent, tolerance-associated process, but can also be immunogenic, depending on death-inducers and environmental context. METHODS To understand ECP mechanisms of action, human alloreactive T cells generated in an in vitro model mimicking GVHD were used, as well as primary cells from GVHD patients. Cells were submitted to PUVA treatment and their phenotype and immunogenicity were analyzed, using cell culture and flow cytometry. RESULTS In vitro PUVA treatment induced the expression of several damage-associated molecular patterns (DAMPs) by dying T cells (calreticulin, high-mobility group box-1, and to a lesser extent heat shock proteins 70 and 90), especially upon T cell activation, leading to their phagocytosis by macrophages and dendritic cells (DCs). Allogeneic DCs preincubated with PUVA treated T cells induced comparable naive T cell proliferation and polarization as control allogeneic DC. CONCLUSION Altogether, in our experimental settings, in vitro PUVA-treatment induces a partially immunogenic phenotype allowing phagocytosis of apoptotic cells by macrophages and DC, however not sufficient to induce dendritic cell maturation and T cell activation. These data refine current models of ECP-mediated immune modulation and emphasize the need to further analyze PUVA-treated cell interactions with immune cells.
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Affiliation(s)
- Céline Coppard
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Dalil Hannani
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France.,PDC*line Pharma, Grenoble, France
| | - Marion Humbert
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Virginie Gauthier
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Joel Plumas
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France.,PDC*line Pharma, Grenoble, France
| | - Etienne Merlin
- Centre Hospitalier Universitaire de Clermont-Ferrand, Pôle Femme-Enfant, Clermont-Ferrand, France
| | - Françoise Gabert
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Laurence Chaperot
- Institute for Advanced Biosciences, Université Grenoble Alpes, INSERM U1209, CNRS UMR 5309, Grenoble, France.,Research and Development, Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
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13
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Adamski J. Vascular access considerations for extracorporeal photopheresis. Transfusion 2018; 58 Suppl 1:590-597. [PMID: 29443405 DOI: 10.1111/trf.14500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/18/2022]
Abstract
Extracorporeal photopheresis is an immunomodulatory therapy indicated for patients with cutaneous T-cell lymphoma, graft-versus-host disease, and heart or lung allograft rejection. Whole blood from the patient is drawn into the photopheresis instrument where it is separated into its components. Plasma, red blood cells, and the treated buffy coat are subsequently returned to the patient. Consistent, adequate blood flow is necessary to successfully complete the procedure. Vascular access options for photopheresis include peripheral vein cannulation, tunneled central venous catheters, and subcutaneous ports. Photopheresis is a very safe procedure; however, the complications and impact on the patient's quality of life associated with vascular access devices can be significant.
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Affiliation(s)
- Jill Adamski
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, Arizona
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14
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Saas P, Bonnefoy F, Toussirot E, Perruche S. Harnessing Apoptotic Cell Clearance to Treat Autoimmune Arthritis. Front Immunol 2017; 8:1191. [PMID: 29062314 PMCID: PMC5640883 DOI: 10.3389/fimmu.2017.01191] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/08/2017] [Indexed: 12/14/2022] Open
Abstract
Early-stage apoptotic cells possess immunomodulatory properties. Proper apoptotic cell clearance during homeostasis has been shown to limit subsequent immune responses. Based on these observations, early-stage apoptotic cell infusion has been used to prevent unwanted inflammatory responses in different experimental models of autoimmune diseases or transplantation. Moreover, this approach has been shown to be feasible without any toxicity in patients undergoing allogeneic hematopoietic cell transplantation to prevent graft-versus-host disease. However, whether early-stage apoptotic cell infusion can be used to treat ongoing inflammatory disorders has not been reported extensively. Recently, we have provided evidence that early-stage apoptotic cell infusion is able to control, at least transiently, ongoing collagen-induced arthritis. This beneficial therapeutic effect is associated with the modulation of antigen-presenting cell functions mainly of macrophages and plasmacytoid dendritic cells, as well as the induction of collagen-specific regulatory CD4+ T cells (Treg). Furthermore, the efficacy of this approach is not altered by the association with two standard treatments of rheumatoid arthritis (RA), methotrexate and tumor necrosis factor (TNF) inhibition. Here, in the light of these observations and recent data of the literature, we discuss the mechanisms of early-stage apoptotic cell infusion and how this therapeutic approach can be transposed to patients with RA.
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Affiliation(s)
- Philippe Saas
- INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Fédération Hospitalo-Universitaire INCREASE, LabEx LipSTIC, Université Bourgogne Franche-Comté, Besançon, France.,INSERM CIC-1431, University Hospital of Besançon, Clinical Investigation Center in Biotherapy, Fédération Hospitalo-Universitaire INCREASE, LabEx LipSTIC, Besançon, France
| | - Francis Bonnefoy
- INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Fédération Hospitalo-Universitaire INCREASE, LabEx LipSTIC, Université Bourgogne Franche-Comté, Besançon, France
| | - Eric Toussirot
- INSERM CIC-1431, University Hospital of Besançon, Clinical Investigation Center in Biotherapy, Fédération Hospitalo-Universitaire INCREASE, LabEx LipSTIC, Besançon, France.,Department of Rheumatology, University Hospital of Besançon, Besançon, France.,Department of Therapeutics, Université Bourgogne Franche-Comté, UPRES EA 4266, Pathogenic Agents and Inflammation, Besancon, France
| | - Sylvain Perruche
- INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Fédération Hospitalo-Universitaire INCREASE, LabEx LipSTIC, Université Bourgogne Franche-Comté, Besançon, France
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15
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Wong RX, Chia JC, Haber RM. Review of Primary Cutaneous Mucinoses in Nonlupus Connective Tissue Diseases. J Cutan Med Surg 2017; 22:65-70. [DOI: 10.1177/1203475417719053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Lichen myxedematosus is an idiopathic, cutaneous mucinosis with 2 clinicopathologic subsets. There is the generalised papular and sclerodermoid form, more properly termed scleromyxedema, and the localised papular form. We report the first case, to our knowledge, of lichen myxedematosus in association with rheumatoid arthritis as well as a case in association with dermatomyositis. An up-to-date literature review on cutaneous mucinoses and connective tissue diseases, excluding the common association of primary and secondary mucinoses with systemic lupus erythematosus, was also performed.
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Affiliation(s)
- Russell X. Wong
- Division of Dermatology, Cumming School of Medicine, Calgary, AB, Canada
| | - Justin C. Chia
- Division of Dermatology, Cumming School of Medicine, Calgary, AB, Canada
| | - Richard M. Haber
- Division of Dermatology, Cumming School of Medicine, Calgary, AB, Canada
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16
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Ipe TS, Pham HP, Williams LA. Critical updates in the 7thedition of the American Society for Apheresis guidelines. J Clin Apher 2017; 33:78-94. [DOI: 10.1002/jca.21562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/17/2017] [Accepted: 05/29/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Tina S. Ipe
- Department of Pathology and Genomic Medicine; Houston Methodist Hospital; Houston Texas
| | - Huy P. Pham
- Department of Pathology, Division of Laboratory Medicine; University of Alabama, Birmingham, Alabama
| | - Lance A. Williams
- Department of Pathology, Division of Laboratory Medicine; University of Alabama, Birmingham, Alabama
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17
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Novel Application of Extracorporeal Photopheresis as Treatment of Graft-versus-Host Disease Following Liver Transplantation. ACG Case Rep J 2017; 4:e48. [PMID: 28377936 PMCID: PMC5371721 DOI: 10.14309/crj.2017.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/17/2017] [Indexed: 12/14/2022] Open
Abstract
A 48-year-old man with hepatitis C virus (HCV) cirrhosis complicated by hepatocellular carcinoma underwent liver transplantation. His course was complicated by fever, diarrhea, abdominal pain, and pancytopenia. He developed a diffuse erythematous rash, which progressed to erythroderma. Biopsies of the colon and skin were consistent with acute graft-versus-host disease. Donor-derived lymphocytes were present in the peripheral blood. The patient was treated with corticosteroids and cyclosporine; however, he had minimal response to intensive immunosuppressive therapy. Extracorporeal photopheresis was initiated as a salvage therapy. He had a dramatic response, and his rash, diarrhea, and pancytopenia resolved. He is maintained on minimal immunosuppression 24 months later.
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18
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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19
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Uygun V, Daloğlu H, Öztürkmen SI, Döşemeci L, Karasu G, Hazar V, Yeşilipek A. Extracorporeal photopheresis did not prevent the development of an autoimmune disease: myasthenia gravis. Transfusion 2016; 56:3081-3085. [DOI: 10.1111/trf.13821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/28/2016] [Accepted: 08/02/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Vedat Uygun
- Pediatric Bone Marrow Transplantation Unit; Medical Park Antalya Hospital, Bahçeşehir University
| | - Hayriye Daloğlu
- Pediatric Bone Marrow Transplantation Unit; Medical Park Antalya Hospital; Antalya Turkey
| | - Seda Irmak Öztürkmen
- Pediatric Bone Marrow Transplantation Unit; Medical Park Antalya Hospital; Antalya Turkey
| | - Levent Döşemeci
- Intensive Care Unit; Istanbul Kemerburgaz University Faculty of Medicine
| | - Gülsün Karasu
- Pediatric Bone Marrow Transplantation Unit, Medical Park Göztepe Hospital; Bahçeşehir University
| | - Volkan Hazar
- Pediatric Hematology and Oncology and Bone Marrow Transplantation Unit; Medipol University Faculty of Medicine; Istanbul Turkey
| | - Akif Yeşilipek
- Pediatric Bone Marrow Transplantation Unit; Medical Park Antalya Hospital, Bahçeşehir University
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20
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Fernández EJ, López C, Ramírez A, Guerra R, López L, Fernández F, Tapia M, García-Cantón C. Papel de la fotoaféresis en el tratamiento del rechazo celular agudo refractario en trasplante renal. Nefrologia 2016; 36:327-8. [DOI: 10.1016/j.nefro.2015.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/15/2015] [Accepted: 06/30/2015] [Indexed: 11/27/2022] Open
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