Plasmapheresis in Raynaud's disease

Therapeutic plasma exchange for the treatment of systemic sclerosis: A comprehensive review and analysis

Background

Therapeutic plasma exchange has been tried as a treatment approach for systemic sclerosis since 1978 based on the rationale that some circulating factor is involved in disease pathogenesis, for example, autoantibodies or immune complexes, and that removing the potential pathogenic factors could lead to symptom improvement. Based on our impression that clinicians and researchers are largely unaware that a large volume of research has been published about the use of therapeutic plasma exchange as a treatment for systemic sclerosis, we conducted a comprehensive review and analysis of all published research on this topic.

Results

We identified 46 relevant articles that met our search criteria, involving a total of 572 patients. Of these, 19 were case studies; the rest ranged from small observational studies to prospective randomized clinical trials. In all but two studies, most patients receiving therapeutic plasma exchange showed improvements in both clinical symptoms and laboratory markers, including significant improvement in Raynaud's symptoms and healing of digital ulceration after three to four weekly treatments. The beneficial effects from even a short course of therapeutic plasma exchange treatments were long-lasting, typically 6 months or longer. Therapeutic plasma exchange was very well tolerated. Adverse events were rare and, in almost all cases, mild and transitory.

Conclusion

These results suggest that long-term therapeutic plasma exchange may offer a low-risk way to control and in some cases reverse systemic sclerosis symptoms. The mechanism for the clinical improvements seen from therapeutic plasma exchange in systemic sclerosis patients is unclear. Therefore, additional studies of therapeutic plasma exchange effects in systemic sclerosis appear to be highly desirable.

Raynaud's phenomenon in the emergency department

Raynaud's phenomenon manifests as triphasic color changes of the digits, induced by exposure to low temperature or emotional stress. It is a relatively common disorder, estimated to affect 5% to 10% of the general population and 25% to 30% of otherwise healthy women. Although usually self-limiting, it can be severely painful and debilitating, and complicated by ulcerations and tissue necrosis. For the emergency physician treating a patient with an acute presentation of the phenomenon, the main challenges are to achieve adequate pain control, reverse vasospasm, and maintain viable tissue. Emergency treatment can also extend to patient education and arrangement of appropriate referrals and follow-up care.

Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma

Arterial spasm due to exaggerated sympathetic response is an important mechanism for Raynaud's phenomenon in scleroderma associated often with periadventitial scarring. The results of cervical sympathectomy have been unsatisfactory in the upper limb because of additional sympathetic pathways. Flatt therefore devised a distal sympathectomy by stripping the vessels of their adventitia over a short length of artery. The results of this operation were found by Wilgis in a large series to be poor in patients with scleroderma. A radical distal microarteriolysis including adventitia and surrounding scar is described and the results in 13 patients, 11 with scleroderma, are reported. Minimum follow-up is one year. All patients had relief from pain at rest and healing of painful ulceration. Mild recurrence of small ulcers was seen in only four patients.

Serum from patients with Raynaud's phenomenon inhibits prostacyclin production

Prostacyclin (PGI2) and PGE2, the predominant cyclooxygenase products of endothelial cells are potent vasodilators. An inability to produce appropriate concentrations of these prostanoids may be a factor in the pathogenesis of the digital vasospasm experienced by patients with Raynaud's phenomenon (RP). The effect of sera from normal subjects, patients with primary RP, and patients with RP in association with systemic sclerosis (SS) on the production of PGI2 and PGE2 by cultured human endothelial cells was investigated. All sera produced a dose-dependent inhibition of 6-keto-PGF1 alpha, but both the 10% and 20% sera from patients with RP and SS produced a significantly greater inhibition than control sera. The mean production of 6-keto-PGF1 alpha expressed in ng/10(4) cells was 2.278 (normal), 1.9311 (RP), and 2.1824 (SS) after incubation with 1% serum for 24 h. This decreased to 1.3647, 0.5927, and 0.4171, respectively following incubation with 20% sera for 24 h. This represented a 44% (normal), 76% (RP), and 83% (SS) inhibition of 6-keto-PGF1 alpha production compared with serum free media. Similar results were obtained after 1 h incubation experiments. There was a nonsignificant decrease in mean PGE2 production following similar incubations with 1% and 20% sera for 24 h. These results suggest that factor(s) present in the sera of patients with RP may reduce the ability of endothelial cells to synthesize or release the vasodilator and antiaggregatory prostanoid PGI2.

Comparison of behavioral treatments for Raynaud's disease

Induced vasodilation by classical conditioning was compared to biofeedback therapy as treatment for idiopathic Raynaud's disease. Classical conditioning therapy consisted of 54 10-min immersions of both hands in water (43 degrees C) simultaneously with whole-body exposure to cold air (0 degrees C), given three times per day, 3 days per week, for 6 weeks. Biofeedback therapy consisted of eight sessions of electromyograph feedback (frontalis) while listening to relaxation tapes, followed by 10 sessions of digital thermal feedback while listening to relaxation tapes. Both groups received 10-min cold stress tests of whole-body exposure to 0 degrees C before and after treatments. Results indicated that both therapies significantly increased the digital temperature response to cold. Although no differences between classical conditioning and biofeedback were found at the end of training, a 1-year follow-up indicated that classical conditioning was more effective.

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.

Therapeutic apheresis

Therapeutic applications using semiautomated blood cell separators have improved the clinical management of several disorders through cellular or plasma depletion, or by rapid erythrocyte or plasma replacement. Cytapheresis procedures may remove large numbers of platelets or leukocytes in proliferative disorders, or induce and maintain a lymphopenia in "autoimmune" diseases. Rapid reductions in circulating paraproteins, autoantibodies, and immune complexes can be achieved to augment longer-term cytotoxic or immunosuppressive therapy. Therapeutic apheresis is adjunctive or palliative, not curative, and is usually short-term rather than chronic. Familiarity with the evolving indications for intervention with apheresis is essential for maximal benefit and minimal risk to the patients recommended for therapy.

Plasma exchange: a controlled study of the effect in patients with Raynaud's phenomenon and scleroderma

Six female patients with stage I and II vascular scleroderma and Raynaud's phenomenon were treated with plasma exchange and placebo plasma exchange. Placebo exchange consisted of the return of the patient's own separated plasma. No consistent long-term objective improvement was demonstrated in patients treated with either plasma exchange or placebo plasma exchange. Immediate increases in pulse volume, digital blood pressure, and skin temperature occurred in some patients with both procedures. Mechanisms of change remain unexplained, and further study is warranted.

Effect of plasma exchange on blood viscosity and cerebral blood flow

The effects of plasma exchange using a low viscosity plasma substitute on blood viscosity and cerebral blood flow were investigated in eight subjects with normal cerebral vasculature. Plasma exchange resulted in significant reductions in plasma viscosity, whole blood viscosity, globulin and fibrinogen concentration without affecting packed cell volume. The reduction in whole blood viscosity was more pronounced at low shear rates suggesting an additional effect on red cell aggregation. Despite the fall in viscosity there was no significant change in cerebral blood flow. The results support the metabolic theory of autoregulation. Although changes in blood viscosity appear not to alter the level of cerebral blood flow under these circumstances, plasma exchange could still be of benefit in the management of acute cerebrovascular disease.

Plasmapheresis and immunosuppressive drug therapy in scleroderma

In an uncontrolled clinical trial, plasmapheresis combined with prednisone and cyclophosphamide therapy produced clinical improvement in 14 of 15 scleroderma patients with varying degrees of skin and internal organ involvement. All improved patients showed a gradual loosening of hide-bound skin, relaxation of contractures, and healing cutaneous ulcers, when present. Severe gastrointestinal symptoms were ameliorated in 4 patients, severe polymyositis was largely reversed in 2 patients, and pulmonary and cardiac function was improved in others. After initial improvement, however, 2 patients died during the period of study and another withdrew unimproved. Antinuclear antibody (ANA) titers declined relatively more than total IgG levels with plasmapheresis in 6 of the 9 patients who had elevated titers. Increased levels of endothelial cell cytotoxic activity found in 11 of the 15 patients were significantly reduced by plasmapheresis. Elevated levels of circulating immune complexes were found in only 4 of the 15 patients. Skin biopsies from adjacent sites taken before and after plasmapheresis in 10 patients all showed less swollen dermal collagen with increased ground substance between collagen bundles in the second biopsy. Although the effects of plasmapheresis cannot be dissociated from those of the immunosuppressive drug therapy, our results suggest that plasmapheresis combined with immunosuppressive drug therapy may find a place in the management of patients with moderate to severe scleroderma. This study implicates circulating factors in the pathogenesis of the disease.

The effect of combination therapy (steroids, immunosuppressives, and plasmapheresis) on 5 mixed cryoglobulinemia patients with renal, neurologic, and vascular involvement

A prospective clinical study evaluated the effects of combined chemotherapy, steroids and plasmapheresis on 5 patients with mixed cryoglobulinemia with renal or neurologic and vasculitic manifestations. Treatment included prednisone (1mg/kg/day), chlorambucil (white blood cell count at greater than 3,000/mm3), and plasmapheresis (1 to 3 liters/week). There was healing of cutaneous ulcers (3/3), improvement in renal function (4/4), and diminution of purpura (2/2), but little improvement in peripheral neuropathy. Complications included leukopenia, perineal ulcers, and osteomyelitis.

Evaluation and management of patients with Raynaud's syndrome

The wide spectrum of associated disorders, the previous lack of understanding of pathogenesis, and the older, arbitrary terminology in relation to ultimate prognosis have led to confusion in the evaluation and management of Raynaud's syndrome. A unified concept of pathogenesis, in which vasospasm and arterial occlusive disease are the fundamental lesions, is presented herein. The associated disorders found in our 219 patients with continuous follow-up are listed and related to the underlying pathogenetic mechanisms. Our approach to diagnosis led to the discovery of an associated condition in 71 percent of our patients. The evaluation can be done in a cost-effective manner. The emphasis of treatment should be on conservative medical management, with avoidance of cold and tobacco and judicious use of pharmacologic agents remaining the cornerstones of therapy. Cervicothoracic sympathectomy has no role in the treatment of Raynaud's syndrome.

Cold hypersensitivity and finger systolic blood pressure in hemodialysis patients

In patients on maintenance hemodialysis the blood pressure in the fingers of the arm with arteriovenous fistula was significantly lower than in the fingers of the other arm. This is explained by the increased arterial blood flow to the arm with the fistula, giving physiological pressure reduction. Six of ten uremic patients on maintenance hemodialysis complained of Raynaud's phenomenon. This was confirmed by a cold provocation test, which showed significant improvement after hemodialysis. The mechanism of Raynaud's phenomenon in these patients is assumed to be functional, but no clear explanation has been found.

Systemic involvement and immunologic findings in patients presenting with Raynaud's phenomenon

Systemic involvement and spectrum of autoantibodies were evaluated in 91 patients presenting with Raynaud's phenomenon. Decreased pulmonary diffusing capacity was observed in 23 percent, esophageal hypomotility in 14 percent and renal involvement in 5 percent of the patients, all without clinical symptoms. Arthralgia or a history of arthritis was present in 27 percent and skin abnormalities in 30 percent. Extent of systemic involvement was correlated with the severity of Raynaud's phenomenon, as measured by photoelectric plethysmography (r = 0.38; p < 0.01). In addition, both the variety of different autoantibodies in the serum of individual patients and the titer of antinuclear antibodies were positively correlated with the number of affected organ systems (r = 0.63; p < 0.01 and r = 0.65; p < 0.01, respectively). Raynaud's phenomenon is an important clinical sign of asymptomatic systemic disease. Measurements of its severity and serologic parameters are helpful in predicting the extent of systemic involvement.

Scleroderma crisis: response to therapy

Renal failure in patients with systemic sclerosis is usually considered irreversible. Presented are two cases of patients with scleroderma and deterioration in renal function, one of whom has responded to therapy which included immunosuppressive agents, plasma exchange, and control of blood pressure.

Blood rheology

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Plasma exchange and Raynaud's phenomenon--its assessment by Doppler ultrasound velocimetry

In a group of 47 patients with Raynaud's phenomenon, Doppler ultrasound velocimetry was used to establish the severity of the disease by detecting the patency of the digital arteries. In conjunction with small digital occlusion cuffs, digital artery systolic pressure was measured on either side of the finger. A significant variation in systolic pressure was detected in each finger, and on each side of individual fingers. A more sensitive index of the severity of the disease was noted when the digital systolic pressure was compared to the brachial systolic pressure. Plasma exchange, a potent method of lowering whole blood viscosity and plasma fibrinogen, was used to treat 18 of these patients. There was a significant improvement in digital vessel patency at both 21 degrees C and 13 degrees C after plasma exchange. Both the digital artery systolic pressure and the pressure index improved significantly after treatment.

Plasma exchange: a selective form of blood-letting

The technique of, and indications for, plasma exchange are presented. This selective form of plasma removal has re-established "blood-letting" in medical therapeutics on a scientific basis. It is the most appropriate therapy when hyperviscosity or haemostatic failure complicate immunoproliferative disease. Plasma exchange is also a significant advance in the management of fulminant forms of autoimmune disease, but in many other conditions it must be regarded as experimental.

Controlled trial of plasma exchange in treatment of Raynaud's syndrome

Twenty-seven patients with Raynaud's syndrome had their digital vessel patency assessed by Doppler ultrasound after different thermal stresses. Digital vessel patency rates differed significantly after stresses at 15 degrees C and 45 degrees C. In a randomised controlled trial placebo and heparin had no effect either on patients' symptoms or on the patency of their digital vessels. Plasma exchange improved both symptoms and vessel patency rates at 15 degrees C and 21 degrees C. Improvement in seven out of eight of these patients has been maintained for six months. Assessing digital vessel patency by Doppler techniques allow continuous, atraumatic, and safe evaluation of the effects of different methods of treatment on the patency of the digital vessels and has helped to indicate that plasma exchange is a useful adjunct in the management of patients with severe Raynaud's syndrome.

Reduction of blood viscosity following plasma exchange

The effect of plasma exchange with plasma protein fraction on blood viscosity was determined in seven hyperlipoproteinaemic patients with coronary or peripheral vascular disease. This resulted in decreases in whole blood viscosity of 83% and 30% respectively at the lowest and highest shear rates studied, and decreases of 21% and 59% in plasma viscosity and fibrinogen. Serum cholesterol and triglyceride were reduced by 66% and 48% respectively. Sequential studies in two patients showed that blood viscosity returned to near-basal values by the 6th day. These findings suggest that plasma exchange may result in short-term enhancement of blood flow in vessels where low shear rates predominate.