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Augusto JF, Benden C, Diekmann F, Zuckermann A. The value of extracorporeal photopheresis as an immunosuppression-modifying approach in solid organ transplantation: a potential solution to an unmet medical need. Front Immunol 2024; 15:1371554. [PMID: 38846942 PMCID: PMC11154098 DOI: 10.3389/fimmu.2024.1371554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Allograft rejection is a critical issue following solid organ transplantation (SOT). Immunosuppressive therapies are crucial in reducing risk of rejection yet are accompanied by several significant side effects, including infection, malignancy, cardiovascular diseases, and nephrotoxicity. There is a current unmet medical need with a lack of effective minimization strategies for these side effects. Extracorporeal photopheresis (ECP) has shown potential as an immunosuppression (IS)-modifying technique in several SOT types, with improvements seen in acute and recurrent rejection, allograft survival, and associated side effects, and could fulfil this unmet need. Through a review of the available literature detailing key areas in which ECP may benefit patients, this review highlights the IS-modifying potential of ECP in the four most common SOT procedures (heart, lung, kidney, and liver transplantation) and highlights existing gaps in data. Current evidence supports the use of ECP for IS modification following SOT, however there is a need for further high-quality research, in particular randomized control trials, in this area.
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Affiliation(s)
- Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, Angers, France
| | | | - Fritz Diekmann
- Renal Transplantation Unit, Department of Nephrology and Kidney Transplantation, Hospital Clinic, Barcelona, Spain
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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2
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Knobler R, Arenberger P, Arun A, Assaf C, Bagot M, Berlin G, Bohbot A, Calzavara-Pinton P, Child F, Cho A, French LE, Gennery AR, Gniadecki R, Gollnick HPM, Guenova E, Jaksch P, Jantschitsch C, Klemke C, Ludvigsson J, Papadavid E, Scarisbrick J, Schwarz T, Stadler R, Wolf P, Zic J, Zouboulis C, Zuckermann A, Greinix H. European dermatology forum: Updated guidelines on the use of extracorporeal photopheresis 2020 - Part 2. J Eur Acad Dermatol Venereol 2020; 35:27-49. [PMID: 32964529 PMCID: PMC7821314 DOI: 10.1111/jdv.16889] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/06/2020] [Indexed: 12/22/2022]
Abstract
Background Following the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T‐cell lymphoma published in 1983, this technology has received continued use and further recognition for additional earlier as well as refractory forms. After the publication of the first guidelines for this technology in the JEADV in 2014, this technology has maintained additional promise in the treatment of other severe and refractory conditions in a multidisciplinary setting. It has confirmed recognition in well‐known documented conditions such as graft‐vs.‐host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection including lung, heart and liver and to a lesser extent inflammatory bowel disease. Materials and methods In order to further provide recognized expert practical guidelines for the use of this technology for all indications, the European Dermatology Forum (EDF) again proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. All authors had the opportunity to review each contribution as it was added. Results and conclusion These updated 2020 guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion. The guidelines were divided into two parts: PART I covers Cutaneous T‐cell lymphoma, chronic graft‐vs.‐host disease and acute graft‐vs.‐host disease, while PART II will cover scleroderma, solid organ transplantation, Crohn’s disease, use of ECP in paediatric patients, atopic dermatitis, type 1 diabetes, pemphigus, epidermolysis bullosa acquisita and erosive oral lichen planus.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Arenberger
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Arun
- FRCPath, The Rotherham NHA Foundation Trust, Rotherham, United Kingdom
| | - C Assaf
- Department of Dermatology and Venerology, Helios Klinikum Krefeld, Krefeld, Germany
| | - M Bagot
- Hospital Saint Louis, Université de Paris, Paris, France
| | - G Berlin
- Department of Clinical Immunology and Transfusion Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Bohbot
- Onco-Hematology Department, Hautepierre Hospital, Strasbourg, France
| | | | - F Child
- FRCP, St John's Institution of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - A Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - L E French
- Department of Dermatology, University Hospital, München, Germany
| | - A R Gennery
- Translational and Clinical Research Institute Newcastle University Great North Children's Hospital Newcastle upon Tyne, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - R Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, Canada
| | - H P M Gollnick
- Department Dermatology & Venereology Otto-von-Guericke University, Magdeburg, Germany
| | - E Guenova
- Faculty of Biology and Medicine, University of Lausanne and Department of Dermatology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - P Jaksch
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - C Jantschitsch
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Klemke
- Hautklinik Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Ludvigsson
- Crown Princess Victoria Children's Hospital and Division of Pediatrics, Department of Biomedical and Clinical Sciences, University Hospital, Linköping University, Linköping, Sweden
| | - E Papadavid
- National and Kapodistrian University of Athens, Athens, Greece
| | - J Scarisbrick
- University Hospital Birmingham, Birmingham, United Kingdom
| | - T Schwarz
- Department of Dermatology, University Clinics Schleswig-Holstein, Kiel, Germany
| | - R Stadler
- University Clinic for Dermatology Johannes Wesling Medical Centre, UKRUB, University of Bochum, Minden, Germany
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - J Zic
- Vanderbilt University Medical Center Department of Dermatology, Nashville, Tennessee, USA
| | - C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - A Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - H Greinix
- LKH-Univ. Klinikum Graz, Division of Haematology, Medical University of Graz, Graz, Austria
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3
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Wiese F, Reinhardt-Heller K, Volz M, Gille C, Köstlin N, Billing H, Handgretinger R, Holzer U. Monocytes show immunoregulatory capacity on CD4 + T cells in a human in-vitro model of extracorporeal photopheresis. Clin Exp Immunol 2018; 195:369-380. [PMID: 30411330 DOI: 10.1111/cei.13232] [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] [Accepted: 10/09/2018] [Indexed: 01/02/2023] Open
Abstract
Extracorporeal photopheresis (ECP) is a widely used immunomodulatory therapy for the treatment of various T cell-mediated disorders such as cutaneous T cell lymphoma (CTCL), graft-versus-host disease (GvHD) or systemic sclerosis. Although clinical benefits of ECP are already well described, the underlying mechanism of action of ECP is not yet fully understood. Knowledge on the fate of CD14+ monocytes in the context of ECP is particularly limited and controversial. Here, we investigated the immunoregulatory function of ECP treated monocytes on T cells in an in-vitro ECP model. We show that ECP-treated monocytes significantly induce proinflammatory T cell types in co-cultured T cells, while anti-inflammatory T cells remain unaffected. Furthermore, we found significantly reduced proliferation rates of T cells after co-culture with ECP-treated monocytes. Both changes in interleukin secretion and proliferation were dependent on cell-contact between monocytes and T cells. Interestingly, blocking interactions of programmed death ligand 1 (PD-L1) to programmed death 1 (PD-1) in the in-vitro model led to a significant recovery of T cell proliferation. These results set the base for further studies on the mechanism of ECP, especially the regulatory role of ECP-treated monocytes.
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Affiliation(s)
- F Wiese
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
| | - K Reinhardt-Heller
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
| | - M Volz
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
| | - C Gille
- Tuebingen University Children's Hospital, Department of Neonatology, Tuebingen, Germany
| | - N Köstlin
- Tuebingen University Children's Hospital, Department of Neonatology, Tuebingen, Germany
| | - H Billing
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
| | - R Handgretinger
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
| | - U Holzer
- Tuebingen University Children's Hospital, Department of Hematology and Oncology, Tuebingen, Germany
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4
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European Reflections on New Indications for Extracorporeal Photopheresis in Solid Organ Transplantation. Transplantation 2018; 102:1279-1283. [DOI: 10.1097/tp.0000000000002244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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5
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Mazzoni A, Giampietro C, Bianco I, Grazzini T, Nencini C, Pileggi C, Scatena F, Filipponi F, Ghinolfi D, Catalano G, Biancofiore G, Bindi M, Urbani L. Extracorporeal photopheresis and liver transplantation: Our experience and preliminary data. Transfus Apher Sci 2017; 56:515-519. [DOI: 10.1016/j.transci.2017.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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6
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Cozzi E, Colpo A, De Silvestro G. The mechanisms of rejection in solid organ transplantation. Transfus Apher Sci 2017; 56:498-505. [PMID: 28916402 DOI: 10.1016/j.transci.2017.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Organ transplantation represents the preferred treatment option for many patients in terminal organ failure. The half-life of transplanted organs, however, is still far from being satisfactory with the vast majority of the organs failing within the first two decades following transplantation. At this stage, it has become apparent that rejection (prevalently mediated by humoral events) remains the primary cause of graft loss after the first year. In this light, studies are underway to better comprehend the immune events underlying graft rejection and novel immunosuppressive strategies are being explored. In this context, therapeutic apheresis techniques, that include therapeutic plasma exchange (TPE), immunoadsorption (IA) and extracorporeal photochemotherapy (ECP), represent an important adjunct in the current immunosuppressive armamentarium. This article briefly reviews our current understanding of the immune process underlying rejection of a solid organ transplant and describes the principal areas of application of therapeutic apheresis techniques in transplantation.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences, Transplant Immunology Unit, Padua University Hospital, Padova, Italy; CORIT (Consortium for Research in Organ Transplantation), Padova, Italy.
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Padova, Italy
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Morelli AE, Larregina AT. Concise Review: Mechanisms Behind Apoptotic Cell-Based Therapies Against Transplant Rejection and Graft versus Host Disease. Stem Cells 2016; 34:1142-50. [PMID: 26865545 DOI: 10.1002/stem.2326] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/10/2016] [Accepted: 01/19/2016] [Indexed: 12/14/2022]
Abstract
The main limitations to the success of transplantation are the antigraft response developed by the recipient immune system, and the adverse side effects of chronic immunosuppression. Graft-versus-host disease (GVHD) triggered by donor-derived T lymphocytes against the recipient tissues is another serious obstacle in the field of hematopoietic stem cell transplantation. Several laboratories have tested the possibility of promoting antigen (Ag)-specific tolerance for therapy of graft rejection, GVHD, and autoimmune disorders, by developing methodologies that mimic the mechanisms by which the immune system maintains peripheral tolerance in the steady state. It has been long recognized that the silent clearance of cells undergoing apoptosis exerts potent immune-regulatory effects and provides apoptotic cell-derived Ags to those Ag-presenting cells (APCs) that internalize them, in particular macrophages and dendritic cells. Therefore, in situ-targeting of recipient APCs by systemic administration of leukocytes in early apoptosis and bearing donor Ags represents a relatively simple approach to control the antidonor response against allografts. Here, we review the mechanisms by which apoptotic cells are silently cleared by phagocytes, and how such phenomenon leads to down-regulation of the innate and adaptive immunity. We discuss the evolution of apoptotic cell-based therapies from murine models of organ/tissue transplantation and GVHD, to clinical trials. We make emphasis on potential limitations and areas of concern of apoptotic cell-based therapies, and on how other immune-suppressive therapies used in the clinics or tested experimentally likely also function through the silent clearance of apoptotic cells by the immune system. Stem Cells 2016;34:1142-1150.
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Affiliation(s)
- Adrian E Morelli
- T.E. Starzl Transplantation Institute, Department of Surgery.,Departments of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, 15213, USA
| | - Adriana T Larregina
- Departments of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, 15213, USA.,Departments of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania, 15213, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, 15213, USA
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8
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Knobler R, Berlin G, Calzavara-Pinton P, Greinix H, Jaksch P, Laroche L, Ludvigsson J, Quaglino P, Reinisch W, Scarisbrick J, Schwarz T, Wolf P, Arenberger P, Assaf C, Bagot M, Barr M, Bohbot A, Bruckner-Tuderman L, Dreno B, Enk A, French L, Gniadecki R, Gollnick H, Hertl M, Jantschitsch C, Jung A, Just U, Klemke CD, Lippert U, Luger T, Papadavid E, Pehamberger H, Ranki A, Stadler R, Sterry W, Wolf IH, Worm M, Zic J, Zouboulis CC, Hillen U. Guidelines on the use of extracorporeal photopheresis. J Eur Acad Dermatol Venereol 2014; 28 Suppl 1:1-37. [PMID: 24354653 PMCID: PMC4291097 DOI: 10.1111/jdv.12311] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND After the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma was published in 1983 with its subsequent recognition by the FDA for its refractory forms, the technology has shown significant promise in the treatment of other severe and refractory conditions in a multi-disciplinary setting. Among the major studied conditions are graft versus host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection and inflammatory bowel disease. MATERIALS AND METHODS In order to provide recognized expert practical guidelines for the use of this technology for all indications the European Dermatology Forum (EDF) proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. RESULTS AND CONCLUSION These guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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9
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Baskaran G, Tiriveedhi V, Ramachandran S, Aloush A, Grossman B, Hachem R, Mohanakumar T. Efficacy of extracorporeal photopheresis in clearance of antibodies to donor-specific and lung-specific antigens in lung transplant recipients. J Heart Lung Transplant 2014; 33:950-6. [PMID: 24906794 DOI: 10.1016/j.healun.2014.04.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 04/30/2014] [Accepted: 04/30/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) has been used to treat chronic rejection after lung transplantation (LTx). We investigated the effect of ECP on several immune parameters that have been associated with poor lung function, including donor-specific antibodies (DSA) to human leukocyte antigen (HLA), antibodies against the lung-associated self-antigens (SAg), Kα1-tubulin (Kα1T), collagen I and V, and circulating levels of pro-inflammatory and anti-inflammatory cytokines. METHODS Sera were collected from post-LTx patients diagnosed with bronchiolitis obliterans before and 6 months after initiation of ECP. DSA and cytokine levels were measured by Luminex (Invitrogen, Carlsbad, CA). Changes in lung function over the 6 months preceding and after the initiation of ECP were measured by retrospective analysis of spirometry performed at routine clinic visits. RESULTS ECP was associated with a significant decline in DSA levels as well as antibodies to lung-associated SAg. ECP also reduced circulating levels of pro-inflammatory cytokines and increased levels of anti-inflammatory cytokines. These immunologic changes were associated with a significant 63% reduction in the rate of decline in forced expiratory volume in 1 second over a 1-year period. Though statistically insignificant, a higher rate of clearance of antibodies to lung-associated SAg was strongly associated with better response to ECP. CONCLUSIONS ECP is associated with a reduction in the levels of circulating DSA, antibodies to lung-associated SAg (Kα1T, collagen I, and collagen V), and circulating levels of several pro-inflammatory cytokines. We propose that these changes contribute to the beneficial effect of ECP in reducing the decline in lung function.
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Affiliation(s)
- Gautam Baskaran
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Aviva Aloush
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Brenda Grossman
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey Hachem
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Thalachallour Mohanakumar
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri.
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Abstract
Since its introduction in photomedicine in 1983 ECP (extracorporeal photopheresis) has over the past decades been established as a safe and effective treatment approach for the palliative management of patients with cutaneous T-cell lymphoma, the Sezary syndrome variant in particular. Subsequently its effectiveness has been well documented in a number of additional T-cell-mediated diseases, particularly in the treatment and prevention of acute and chronic graft-vs. -host disease. More recently, ECP has been successfully used to treat acute heart allograft rejection and chronic allograft dysfunction after lung transplantation without increasing infectious complications. As recently documented ECP was also used as a part of CNI (calcineurin inhibitors) sparing or staggering protocols. For this group of patients it is proposed that its efficacy may be partly attributed through direct induction of lymphocyte apoptosis (Tambur et al., 2000) [1] and subsequent production of regulatory T cells (Treg) (Lamioni et al., 2007) [2,3] without causing general immunosuppression. However, the exact indications for use of ECP within this framework are not yet finalized.
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Affiliation(s)
- Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Austria
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Austria.
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Worel N, Leitner G. Clinical Results of Extracorporeal Photopheresis. ACTA ACUST UNITED AC 2012; 39:254-262. [PMID: 22969695 DOI: 10.1159/000341811] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 07/12/2012] [Indexed: 01/04/2023]
Abstract
Extracorporeal photopheresis (ECP) is a combination of leukapheresis and photodynamic therapy in which blood is treated with photoactivable drugs which are then activated with ultraviolet light and re-infused to the patient. It has been used successfully for more than 30 years in the treatment of erythrodermic cutaneous T-cell lymphoma (CTCL) and over 20 years for chronic graft-versus-host disease (GVHD). ECP has also shown promising results in the treatment of acute GVHD and other T-cell-mediated diseases, including systemic sclerosis, treatment and prevention of solid organ rejection, and more recently Crohn's disease. The use of ECP may allow a significant reduction or even discontinuation of corticosteroids and/or other immunosuppressants, thus leading to reduced long-term morbidity and mortality and improved overall survival. ECP is a well-tolerated therapy. No significant side effects have been reported during the last 30 years. It has been shown that ECP is not associated with an increased incidence of infections, malignancies, or recurrence of underlying malignant disease, neither during short-term nor during long-term therapy.
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Affiliation(s)
- Nina Worel
- Department for Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Austria
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12
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Ward DM. Extracorporeal photopheresis: How, when, and why. J Clin Apher 2011; 26:276-85. [DOI: 10.1002/jca.20300] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/05/2011] [Indexed: 12/14/2022]
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Failli A, Legitimo A, Mazzoni A, Urbani L, Scatena F, Mosca F, Consolini R. The Combination of Immunosuppressive Drugs with 8-Methoxypsoralen and Ultraviolet a Light Modulates the Myeloid-Derived Dendritic Cell Function. Int J Immunopathol Pharmacol 2011; 24:89-99. [DOI: 10.1177/039463201102400111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The functional properties of myeloid dendritic cells (DCs) differ, depending on microenvironmental factors as well as on their stage of maturation. The main approaches for the selective enhancement of the tolerogenic properties of DCs include the induction of a pharmacological arrest of the DCs maturation and the genetical engineering of DCs expressing immunosuppressive molecules. Several immunosuppressive/anti-inflammatory agents have been discovered that potentially inhibit DC maturation and immunogenicity. Photopheresis (ECP) is an immunomodulatory therapy in which leucocytes are exposed to 8-methoxypsoralen (8-MOP) and ultraviolet (UV) A radiation (PUVA). The combination of ECP with immunosuppressive agents has demonstrated efficacy in the management of transplanted patients by reducing either the incidence of organ rejection or the pharmacological toxicity. In particular, we have observed in hepatitis C virus (HCV)-positive patients that the same combination has reduced the immunosuppressive burden and improved sustainability and efficacy of pre-emptive antiviral therapy after liver transplantation. Therefore, in our work we investigated the in vitro effects of PUVA, combined with immunosuppressive drugs (IDs), on both in vitro human DC generation and maturation, in order to contribute to understanding the immunological mechanisms underlying this pharmacological combination. Monocyte PUVA-treatment was performed by using an in vitro experimental protocol that we previously described. PUVA-treated or -untreated highly purified CD14+ cells were incubated with the association of the immunosuppressive drugs, used in the management of liver transplantation, at two different concentrations, in the presence of IL-4 and GM-CSF. The treatment with IDs at the highest concentration (corresponding to that used in clinical practice), alone or in association with PUVA, induced an immunosuppressive effect, by impairing both DC generation and maturation. Neither immunosuppressive drugs at the lowest concentration nor their combination with PUVA affected myeloid DC generation, but modified DC functions, strengthening the induction of a tolerogenic pattern. As this ID concentration was arbitrarily chosen, further experiments could highlight whether lower concentrations than those used in clinical practice would elicit the same effect on DCs and potentially improve their functional properties. This work describes an original experimental approach exploring the in vitro mechanism of action of the combined procedure of PUVA with immunosuppressive drugs, used in liver transplantation, on DCs generation and function. Our results contribute to the knowledge of the mechanisms of action of this combined procedure on DCs, suggesting useful therapeutic implications for the in vivo therapy.
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Affiliation(s)
- A. Failli
- Department of Reproductive Medicine and Pediatrics, Laboratory of Immunology, University of Pisa
| | - A. Legitimo
- Department of Reproductive Medicine and Pediatrics, Laboratory of Immunology, University of Pisa
| | - A. Mazzoni
- Blood Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Pisa
| | - L. Urbani
- Department of Liver Transplantation, General Surgery and Liver Transplantation Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Pisa
| | - F. Scatena
- Blood Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Pisa
| | - F. Mosca
- Department of Oncology, Transplants and New Technologies in Medicine, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital Pisa, Italy
| | - R. Consolini
- Department of Reproductive Medicine and Pediatrics, Laboratory of Immunology, University of Pisa
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Abstract
One of the ultimate goals in transplantation is to develop novel therapeutic methods for induction of donor-specific tolerance to reduce the side effects caused by the generalized immunosuppression associated to the currently used pharmacologic regimens. Interaction or phagocytosis of cells in early apoptosis exerts potent anti-inflammatory and immunosuppressive effects on antigen (Ag)-presenting cells (APC) like dendritic cells (DC) and macrophages. This observation led to the idea that apoptotic cell-based therapies could be employed to deliver donor-Ag in combination with regulatory signals to recipient’s APC as therapeutic approach to restrain the anti-donor response. This review describes the multiple mechanisms by which apoptotic cells down-modulate the immuno-stimulatory and pro-inflammatory functions of DC and macrophages, and the role of the interaction between apoptotic cells and APC in self-tolerance and in apoptotic cell-based therapies to prevent/treat allograft rejection and graft-versus-host disease in murine experimental systems and in humans. It also explores the role that in vivo-generated apoptotic cells could have in the beneficial effects of extracorporeal photopheresis, donor-specific transfusion, and tolerogenic DC-based therapies in transplantation.
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15
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Balogun RA, Kaplan A, Ward DM, Okafor C, Burns TM, Torloni AS, Macik BG, Abdel-Rahman EM. Clinical applications of therapeutic apheresis. J Clin Apher 2010; 25:250-64. [DOI: 10.1002/jca.20249] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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16
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Morruzzi C, Liu V, Bohbot A, Cribier B, Lipsker D. [Four cases of photopheresis treatment for cutaneous lupus erythematosus refractory to standard therapy]. Ann Dermatol Venereol 2010; 136:861-7. [PMID: 20004310 DOI: 10.1016/j.annder.2009.10.183] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 09/18/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Photopheresis is a leucopheresis procedure in which cells are photoactivated by psoralen and then irradiated by ultraviolet A. We report four cases of women with refractory cutaneous lupus erythematosus (LE) who responded to this treatment. PATIENTS AND METHODS We treated one patient with subacute LE having a contraindication to antimalarials and to thalidomide and three patients with chronic LE (lupus panniculitis, lupus tumidus and disseminated discoid LE) refractory to treatment with hydroxychloroquine, chloroquine, thalidomide and dapsone, and also, in some cases, to oral and intravenous corticosteroids, methotrexate, colchicine, acitretine, sulfasalazine, mycophenolate mofetil and intravenous immunoglobulin. Treatment consisted of two 4-hour sessions fortnightly. Only antimalarials were continued during photopheresis. RESULTS Photopheresis had a positive effect on all four patients. We noticed complete remission in two patients and interruption of progression followed by partial remission in the other two after a mean delay of two to three months of treatment. All treatments other than antimalarials were stopped. DISCUSSION Photopheresis appears to be an effective treatment option in patients with cutaneous LE. Due to its high cost, it should nevertheless remain an exceptional therapeutic option restricted to patients with cutaneous LE resistant to standard therapy.
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Affiliation(s)
- C Morruzzi
- Clinique dermatologique, hôpital Civil, CHU de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
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Urbani L, Mazzoni A, Bindi L, Biancofiore G, Bisà M, Meacci L, Esposito M, Mozzo R, Colombatto P, Bianco I, Grazzini T, Coletti L, De Simone P, Catalano G, Montin U, Tincani G, Balzano E, Petruccelli S, Carrai P, Tascini C, Menichetti F, Scatena F, Filipponi F. A single-staggered dose of calcineurin inhibitor may be associated with neurotoxicity and nephrotoxicity immediately after liver transplantation. Clin Transplant 2009; 23:853-60. [DOI: 10.1111/j.1399-0012.2009.00957.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Extracorporeal photopheresis: From solid organs to face transplantation. Transpl Immunol 2009; 21:117-28. [DOI: 10.1016/j.trim.2009.04.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/19/2009] [Accepted: 04/24/2009] [Indexed: 12/21/2022]
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A Novel Immunosuppressive Strategy Combined with Preemptive Antiviral Therapy Improves the Eighteen-Month Mortality in HCV Recipients Transplanted with Aged Livers. Transplantation 2008; 86:1666-71. [DOI: 10.1097/tp.0b013e31818fe505] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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