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Rashidi M, Naghavi S, Ramezani N, Ashtari F, Shaygannejad V, Hosseini SM, Adibi I. Early clinical response and complications of therapeutic plasma exchange in central nervous system demyelinating diseases. J Cent Nerv Syst Dis 2024; 16:11795735241262738. [PMID: 38903856 PMCID: PMC11188695 DOI: 10.1177/11795735241262738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/27/2024] [Indexed: 06/22/2024] Open
Abstract
Background Appropriate treatment reduces the severity and duration of relapses in demyelinating diseases of Central Nervous System (CNS). If high-dose corticosteroids treatment fails, therapeutic plasma exchange (TPE) is considered as a rescue treatment. Objectives This study aimed to investigate early clinical response and complications of TPE and prognostic factors in CNS demyelinating relapses. Design This prospective observational study was designed in a tertiary center during one year. Methods All adult patients diagnosed corticosteroid-resistant Multiple Sclerosis (MS), NeuroMyelitis Optica Spectrum Disorder (NMOSD), idiotypic Transverse Myelitis or Clinical Isolated Syndrome relapses, were eligible. Clinical response is defined based on Expanded Disability Status Scale (EDSS) at discharge. Clinical and laboratory complications recorded. Results Seventy-two patients were analyzed which 58.3% patients were female. MS was diagnosed for 61.1% of cases. Thirty-five patients (48.6%) responded and the mean differences of EDSS significantly decreased 0.60 score (CI95%:0.44-.77). Electrolyte imbalances and thrombocytopenia occurred in 80.6% and 55.6% of cases respectively and 40.3% of patients had systemic reactions. However, 26.4% patients experienced moderate to severe complications. In patients with moderate to severe disability, responders were younger (MD: 8.42 years, CI95%: 1.67-15.17) and had lower EDSS score at admission (median:6, IQR: 5.5-6 against 7.5 IQR: 6.5-8). The risk of failure was higher in active progressive MS patients compared with RRMS patients (OR: 6.06, CI 95%:1.37-26.76). Patients with thrombocytopenia were hospitalized more than others (MD: 1.5 days, CI 95%: 0-3). Females were more prone to hypokalemia and systemic reactions (OR: 3.11, CI 95%:1.17-8.24 and OR: 6.67, CI 95%:2.14-20.81 respectively). Conclusion The most common indication of TPE was corticosteroid-resistant severe MS relapses. About half of the patients presented an early clinical response. Lower disability, younger age and RRMS diagnosis are prognostic factors of better response. One out of four patients experienced moderate to severe complications, mainly electrolyte imbalances and systemic reactions. Appropriate interventions against these complications should be considered during TPE, especially in females.
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Affiliation(s)
- Mehran Rashidi
- Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Naghavi
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Neda Ramezani
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fereshteh Ashtari
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Shaygannejad
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sayed Mohsen Hosseini
- Department of Biostatistics & Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Iman Adibi
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran
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de Almeida GMR, de Araujo RS, Castrillo BB, Silva GD, Fortini I, Gonçalves MRR, Castro LHM, Tatsui NH, Adoni T, Sato DK, Apóstolos-Pereira SL, Callegaro D. Therapeutic plasma exchange for neuromyelitis optica attacks: Evidence and challenges from a real-world cohort from Brazil. J Neuroimmunol 2024; 388:578295. [PMID: 38280268 DOI: 10.1016/j.jneuroim.2024.578295] [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: 12/04/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 01/29/2024]
Abstract
Therapeutic plasma exchange (TPE) can improve disability recovery after neuromyelitis optica spectrum disease (NMOSD) attacks, but its effectiveness and safety in Latin-American patients with access barriers and diverse ethnicity is underexplored. We carried out a retrospective cohort study with NMOSD patients that underwent TPE. 84 NMOSD attacks in 68 patients were evaluated. Despite a median 25-day delay from symptom onset to TPE, 65,5% of patients showed significant improvement. Adverse events occurred in 39% of patients, usually transitory and with no fatalities.
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Affiliation(s)
- Guilherme Mello Ramos de Almeida
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil; Hospital Cardio Pulmonar da Bahia, Salvador, Bahia, Brazil
| | - Roger Santana de Araujo
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.
| | - Bruno Batitucci Castrillo
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil; Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Espírito Santo, Brazil
| | - Guilherme Diogo Silva
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Ida Fortini
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | | | - Luiz Henrique Martins Castro
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Nelson Hidekazu Tatsui
- Hematology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Tarso Adoni
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Douglas Kazutoshi Sato
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil; School of Medicine and Institute for Geriatrics and Gerontology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Dagoberto Callegaro
- Neuroimmunology Group, Neurology Department, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
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Queiroz ALGD, Soares Neto HR, Kobayashi TT, Silva SMCDA. Plasma exchange in inflammatory demyelinating disorders of the central nervous system: reasonable use in the clinical practice. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:296-307. [PMID: 37059439 PMCID: PMC10104758 DOI: 10.1055/s-0042-1758447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Plasma exchange (PLEX) is a therapeutic apheresis modality in which the plasma is separated from inflammatory factors such as circulating autoreactive immunoglobulins, the complement system, and cytokines, and its therapeutic effect is based on the removal of these mediators of pathological processes. Plasma exchange is well established for various neurological disorders, and it is applied successfully in central nervous system inflammatory demyelinating diseases (CNS-IDD). It mainly modulates the humoral immune system; thus, it has a greater theoretical effect in diseases with prominent humoral mechanisms, such as neuromyelitis optica (NMO). However, it also has a proven therapeutic effect in multiple sclerosis (MS) attacks. Several studies have suggested that patients with severe attacks of CNS-IDD have poor response to steroid therapy but show clinical improvement after the PLEX treatment. Currently, PLEX is generally established only as a rescue therapy for steroid unresponsive relapses. However, there are still research gaps in the literature regarding plasma volume, number of sessions, and how early the apheresis treatment needs to started. Thus, in the present article, we summarize the clinical studies and meta-analyses, especially about MS and NMO, outlining clinical data regarding the experience with therapeutic PLEX in severe attacks of CNS-IDD, the clinical improvement rates, the prognostic factors of a favorable response, and highlighting the likely role of the early apheresis treatment. Further, we have gathered this evidence and suggested a protocol for the treatment of CNS-IDD with PLEX in the routine clinical practice.
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Affiliation(s)
| | | | - Thiago Taya Kobayashi
- Hospital do Servidor Público Estadual de São Paulo, Serviço de Neurologia, São Paulo SP, Brazil
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Shi M, Chu F, Jin T, Zhu J. Progress in treatment of neuromyelitis optica spectrum disorders (NMOSD): Novel insights into therapeutic possibilities in NMOSD. CNS Neurosci Ther 2022; 28:981-991. [PMID: 35426485 PMCID: PMC9160456 DOI: 10.1111/cns.13836] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/18/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune inflammatory demyelinating disorder of the central nervous system (CNS), which is a severely disabling disorder leading to devastating sequelae or even death. Repeated acute attacks and the presence of aquaporin-4 immunoglobulin G (AQP4-IgG) antibody are the typical characteristics of NMOSD. Recently, the phase III trials of the newly developed biologicals therapies have shown their effectiveness and good tolerance to a certain extent when compared with the traditional therapy with the first- and second-line drugs. However, there is still a lack of large sample, double-blind, randomized, clinical studies to confirm their efficacy, safety, and tolerability. Especially, these drugs have no clear effect on NMOSD patients without AQP4-IgG and refractory patients. Therefore, it is of strong demand to further conduct large sample, double-blind, randomized, clinical trials, and novel therapeutic possibilities in NMOSD are discussed briefly here.
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Affiliation(s)
- Mingchao Shi
- Neuroscience CenterDepartment of NeurologyThe First Hospital of Jilin UniversityChangchunChina
- Department of Neurobiology, Care Sciences & SocietyDivision of NeurogeriatrcsKarolinska InstitutetKarolinska University Hospital SolnaStockholmSweden
| | - Fengna Chu
- Neuroscience CenterDepartment of NeurologyThe First Hospital of Jilin UniversityChangchunChina
- Department of Neurobiology, Care Sciences & SocietyDivision of NeurogeriatrcsKarolinska InstitutetKarolinska University Hospital SolnaStockholmSweden
| | - Tao Jin
- Neuroscience CenterDepartment of NeurologyThe First Hospital of Jilin UniversityChangchunChina
| | - Jie Zhu
- Neuroscience CenterDepartment of NeurologyThe First Hospital of Jilin UniversityChangchunChina
- Department of Neurobiology, Care Sciences & SocietyDivision of NeurogeriatrcsKarolinska InstitutetKarolinska University Hospital SolnaStockholmSweden
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Li R, Wang J, Li C, Liu X, Chu M, Chang Y, Wang Y, Wang X, Yu B, Ling L, Yang H, Yang H, Hu X, Qiu W. Rescue immunoadsorption treatment for neuromyelitis optica spectrum disorder attacks unresponsive to intravenous methylprednisolone. J Neuroimmunol 2021; 356:577604. [PMID: 33992860 DOI: 10.1016/j.jneuroim.2021.577604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 02/06/2023]
Abstract
We aimed to evaluate the value of immunoadsorption (IA) treatment after the failure of intravenous methylprednisolone (IVMP) therapy for neuromyelitis optica spectrum disorder (NMOSD). Sixty-one NMOSD attacks unresponsive to IVMP were included: 22 patients received rescue IA (IVMP+IA), 24 underwent rescue plasma exchange (PE) (IVMP+PE), and 21 received no further rescue therapy (IVMP alone). The improvement frequencies were higher in the IVMP+IA and IVMP+PE groups than in the IVMP-alone group (P = 0.024). The effective period for IA treatment may be longer than previously thought. IA treatment for IVMP-resistant NMOSD attacks was effective and comparable to PE treatment.
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Affiliation(s)
- Rui Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Jingqi Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cong Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xiangfu Liu
- Department of Blood Transfusion, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Muyang Chu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Yanyu Chang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yuge Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xia Wang
- Neurology Department, The Sixth People's Hospital of Huizhou, Huizhou 516200, China
| | - Boguang Yu
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology, Guangzhou 510700, China
| | - Li Ling
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Hui Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center of Sun Yat-sen University, Guangzhou 510060, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.
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Viswanathan S, Schee JP, Omar MA, Hiew FL. Sequential intermittent therapeutic plasma exchange: A possible induction and maintenance therapy in the management of adult patients with neuromyelitis optica spectrum disorder. Ther Apher Dial 2020; 25:513-532. [DOI: 10.1111/1744-9987.13595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 07/28/2020] [Accepted: 10/04/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | - Jie Ping Schee
- Department of Neurology Kuala Lumpur General Hospital Kuala Lumpur Malaysia
- Department of Medicine Tawau Hospital Sabah Malaysia
| | - Mohd Azahadi Omar
- National Institutes of Health Ministry of Health Malaysia Selangor Malaysia
| | - Fu Liong Hiew
- Department of Neurology Kuala Lumpur General Hospital Kuala Lumpur Malaysia
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Therapeutic Plasma Exchange as a Treatment for Autoimmune Neurological Disease. Autoimmune Dis 2020; 2020:3484659. [PMID: 32802495 PMCID: PMC7415086 DOI: 10.1155/2020/3484659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction Therapeutic plasma exchange (TPE) is commonly used as treatment of certain autoimmune neurological diseases (ANDs), and its main objective is the removal of pathogenic autoantibodies. Our aim was to describe the clinical profile and the experience with the usage of TPE in patients with ANDs at our institution. Methods This is an observational retrospective study, including medical records of patients with diagnosis of ANDs who received TPE, between 2011 and 2018. Characteristics of TPE, such as number of cycles, type of replacement solution, and adverse effects, were evaluated. The modified Rankin Scale (mRS) was applied to measure the clinical response after the therapy. Results 187 patients were included with the following diagnoses: myasthenia gravis (MG), n = 70 (37%); Guillain–Barré syndrome (GBS), n = 53 (28.3%), neuromyelitis optica spectrum disorders (NMOSD), n = 35 (18.7%); chronic inflammatory demyelinating polyneuropathy (CIDP), n = 23 (12.2%); and autoimmune encephalitis (AE), n = 6 (3.2%). The most used types of replacement solution were albumin (n = 131, 70%) and succinylated gelatin (n = 45, 24%). All patients received a median of five cycles (IQR 5-5). Hypotension and hydroelectrolytic disorders were the main complications. After TPE, 99 patients (52.9%) showed improvement in the mRS scores and a statistical significance (p < 0.05) was seen between the admission score and after TPE for every diagnosis except for CIDP. Conclusion TPE has an adequate safety profile, and improvement in functionality in treated patients reflects its effectiveness.
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