Predictive factors of response to leukocytapheresis therapy for ulcerative colitis

Caudal type homeobox 2 expression induced by leukocytapheresis might be associated with mucosal healing in ulcerative colitis

BACKGROUND AND AIM

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon with an intractable, recurrent course. Although the goal of UC therapy has recently been to target mucosal healing, the molecular mechanism of mucosal healing remains unknown. In this study, we aimed to elucidate the molecular dynamics related to the proliferation and differentiation of intestinal epithelial cells during cytapheresis therapy in a short duration.

METHODS

Endoscopy was performed in 26 patients with UC in multicentre hospitals, and biopsy specimens were collected from the rectum before and within two weeks after leukocytapheresis (LCAP). The expression of representative proteins in intestinal epithelial cells and pathological findings was compared before and after LCAP.

RESULTS

The expression of caudal type homeobox 2 (CDX2) and a hes family bHLH transcription factor 1(HES1) markedly increased after LCAP. Patients with endoscopic improvement after LCAP showed the expression of CDX2 before LCAP. Moreover, the number of goblet cells significantly increased after LCAP. Patients without endoscopic improvement after LCAP did not show the expression of CDX2 before LCAP. However, the expression of CDX2 markedly increased after LCAP.

CONCLUSION

This study suggests that cytapheresis might induce CDX2 expression without affecting the cell proliferation, thus resulting in mucosal healing with goblet cell restoration.

Microarray analyses of peripheral whole blood cells from ulcerative colitis patients: effects of leukocytapheresis

Complementary DNA microarray technology allows the simultaneous analysis of the expression of hundreds to thousands of genes. We applied this technique to clarify the molecular mechanisms underlying the therapeutic effects of leukocytapheresis (LCAP) therapy in patients with ulcerative colitis (UC). A 776-gene microarray analysis was performed using whole blood cells from six normal subjects and six patients with active UC who had undergone filtration LCAP. Widespread gene upregulation was observed in patients with UC, compared with normal subjects. After LCAP, genes with proinflammatory actions, such as CD97, CD74, human leukocyte antigen-DRβ1 and -DP light chain, were downregulated, while genes responsible for antimicrobial actions, such as neutrophil gelatinase-associated lipocalin, and acute phase reactions, such as haptoglobin α1S and α1-acid glycoprotein, were upregulated. In conclusion, we identified several genes expressed in the whole blood cells of UC patients as well as the transcriptional events following LCAP. Following LCAP, the gene profile shifted toward a pattern indicating disease improvement. These results suggest a basis for the molecular mechanisms leading to the therapeutic effects of LCAP and also indicate new therapeutic targets, providing important prognostic information.

Therapeutic leukocytapheresis in inflammatory bowel disease: clinical efficacy and mechanisms of action

Intense infiltration of the intestinal mucosa by activated leukocytes is a hallmark of inflammatory bowel disease (IBD). Therefore, removal of circulating leukocytes may be an attractive approach for treating IBD. Leukocytapheresis with Cellsorba, a column of polyethylenephtarate fibers that captures monocytes, granulocytes and lymphocytes, has been used to treat IBD, particularly ulcerative colitis, in Japan and Europe. This article reviews the clinical efficacy and safety data and the mechanisms of action of leukocytapheresis in IBD. Although the majority of clinical studies enrolled only small numbers of patients and had open-labeled designs, leukocytapheresis showed clinical efficacy with an excellent safety profile. Leukocytapheresis depletes granulocytes, monocytes, lymphocytes and platelets, alters cell population profiles, modulates cytokine production, and induces bone marrow-derived cells. In conclusion, leukocytapheresis exerts anti-inflammatory and tissue-repairing effects on the intestinal mucosa in IBD. Further studies are needed to explain the exact mechanism of action and to determine the true efficacy of this approach.

A pilot study of leukocytapheresis efficacy with 1.5 liter blood processing volume in patients with ulcerative colitis

Standard leukocytapheresis (LCAP) protocols recommend the processing of a 3 L blood volume. In this study, we evaluated the clinical effects of LCAP with 1.5 L of blood processing (1.5L-LCAP) in patients with active ulcerative colitis (UC). Ten patients with moderate to severe UC were enrolled. Their clinical and endoscopic responses, the kinetics of the peripheral blood counts and cytokine responses were evaluated. Clinical and endoscopic effects were assessed using the clinical activity index described by Rachmilewitz, and by Matts' endoscopic classification, respectively. The 1.5L-LCAP induced clinical remission in 8 out of 10 patients (80%). Endoscopic improvement was noted in 6 out of 7 patients (85.7%). Prednisolone (PSL) was used in 8 patients; the PSL dose could be reduced in 6 patients, and weaning was possible in one patient. Adverse effects were not observed during 1.5L-LCAP therapy. During the 1.5L-LCAP session, the leukocyte count reached the minimum at 1.0 L of blood processing, but promptly increased after completion of the session, and reached a maximum after 30 min. Interleukin (IL)-1beta-induced IL-8 and IL-6 secretion by peripheral blood mononuclear cells were both significantly reduced by 1.5L-LCAP therapy. 1.5L-LCAP was clinically effective for active UC patients. Cellular responses induced by 1.5L-LCAP were similar to those induced by a standard LCAP session.

Mobilization of bone marrow cells by leukocytapheresis in patients with ulcerative colitis

While several trials have suggested that leukocytapheresis by filtration can benefit patients with active ulcerative colitis (UC), mechanisms underlying these benefits are largely unknown. We studied how leukocytapheresis mobilizes bone marrow cells into the peripheral circulation in patients with active UC. Leukocytapheresis transiently reduced peripheral leukocytes, followed by an overshoot increase with emergence of immature leukocytes. The numbers of colonies and CD34(+) cells were comparable between UC patients and normal controls. Shortly after leukocytapheresis, the numbers of both colonies and CD34(+) cells increased significantly in UC patients (P < 0.0001 and P = 0.0372, respectively). This was not associated with changes in the concentration of circulating cytokines or epinephrine. These results indicate that leukocytapheresis mobilizes bone marrow cells into the circulation. This cell replacement may partly explain the therapeutic benefit in UC. The functional role of the mobilized bone marrow cells in affected intestine remains to be characterized.

Microarray analysis of leukocytapheresis-induced changes in gene expression patterns of peripheral blood mononuclear cells in patients with ulcerative colitis

To elucidate the molecular mechanisms involved in the therapeutic effects of leukocytapheresis (LCAP), we performed microarray analysis for gene expression patterns in peripheral blood mononuclear cells (PBMCs) before and after LCAP therapy in patients with ulcerative colitis (UC). Four patients with UC were enrolled. PBMCs were isolated from peripheral venous blood obtained within 5 min before and after the first session of LCAP therapy. Cells were stimulated with IL-1beta for 12 h, and gene expression patterns were analyzed by an IntelliGene HS Human Expression Chip. The LCAP session reduced various genes, such as proinflammatory cytokines (IL-1alpha, IL-1beta, IL-6, IL-8, TNF-alpha, and IFN-gamma), cytokine receptors (IL-1R and IL-2Ralpha), chemokines, chemokine receptors, and intracellular signal transduction molecules. Genes which had increased after the LCAP session included those regulating anti-inflammatory cytokines and proteins (TGF-beta1 and IL-R antagonist), receptors for anti-inflammatory cytokines (IL-10R and IL-4R), growth factor receptors (IGF-R1, R2) and antioxidant proteins. Total changes in gene expression patterns after LCAP session were a combination of a decrease in pro-inflammatory genes and an enhancement of anti-inflammatory genes. These changes may explain some parts of the mechanisms by which LCAP improves clinical symptoms of UC patients.

Review article: the management of steroid dependency in ulcerative colitis

BACKGROUND

Approximately 20% of patients with ulcerative colitis have a chronic active disease often requiring several courses of systemic steroids in order to achieve remission, but followed by relapse of symptoms during steroid tapering or soon after their discontinuation. Although short term control of symptoms can be achieved with steroid treatment, this pattern of drug response, known as steroid-dependency, leads to important complications of the treatment, while a significant proportion of patients requires colectomy.

AIM

To review the studies currently available specifically evaluating the management of steroid-dependent ulcerative colitis.

RESULTS

The clinical and biological mechanisms of steroid-dependency are not well understood compared with those determining steroid-refractoriness. Very few evidence-based data are available concerning the management of patients with steroid-dependent ulcerative colitis. The therapeutic role of aminosalicylates, thiopurines, methotrexate, infliximab, leukocyte apheresis and other drugs in the treatment of steroid-dependent ulcerative colitis are evaluated.

CONCLUSIONS

Outcomes of studies in steroid-refractory patients may not be applicable to steroid-dependency. Trials are needed to define the correct approaches and new strategies to ameliorate the therapy of steroid-dependent ulcerative colitis.

Predictive factors of efficacy of leukocytapheresis for steroid-resistant ulcerative colitis patients

BACKGROUND

The effectiveness of leukocytapheresis against ulcerative colitis has been reported. However, the efficacy of this therapy for steroid-resistant ulcerative colitis patients has hardly been examined.

AIMS

The aims of this study are to evaluate the efficacy of leukocytapheresis for steroid-resistant ulcerative colitis patients and to identify clinical factors that predict the efficacy of this therapy for these patients.

METHODS

Clinical factors of 71 steroid-resistant ulcerative colitis patients who underwent leukocytapheresis analysed.

RESULTS

Of those analysed, 53 (75%) patients showed an initial response to leukocytapheresis. Among cases with initial response, however, only 19 (27%) patients maintained remission for more than 6 months. Steroid-dependent course (Odds ratio =5.53, 95% confidence interval; 1.24-24.73) and a high C-reactive protein degree (Odds ratio=1.6, confidence interval; 1.09-2.35) were predictors of initial response to leukocytapheresis. Rapid response, which means remission induction within three leukocytapheresis sessions, was the only predictor of maintenance of remission for more than 6 months after successful leukocytapheresis therapy (odds ratio=8.01, confidence interval; 1.08-59.37).

CONCLUSIONS

Leukocytapheresis was effective for steroid-resistant ulcerative colitis patients. However, relapse was frequently observed within short periods after the initial response to this therapy. Patients without a rapid response should be treated with alternative or additional therapies.

Fluctuations in Peripheral Blood Leukocyte and Platelet Counts and Leukocyte Recruitment With Large Volume Leukocytapheresis in Healthy Volunteers

Based on sporadic reports indicating that the effectiveness of leukocytapheresis (LCAP) is proportional to the number of leukocytes removed, it is anticipated that increasing the volume of blood treated, and thus the number of leukocytes removed, will improve the effectiveness of therapy. In advance of its clinical application, the possible clinical usefulness of large volumes of LCAP (pulse LCAP), which treats 5000 mL of blood rather than the usual volume of 3000 mL, was investigated in healthy subjects. As compared with conventional LCAP, pulse LCAP provided comparable safety and enabled the removal of approximately 4.7 times more neutrophils, 1.2 times more lymphocytes, and 1.6 times more monocytes. It also resulted in a more pronounced overshoot phenomenon, as well as lymphocyte and monocyte overshoot, which are not seen with conventional LCAP. The neutrophil overshoot resulted from the recruitment of leukocytes from the bone marrow neutrophil pool as well as from the circulating neutrophil pool and marginal neutrophil pool. Recruitment from the bone marrow pool involved not only recruitment of mature neutrophils but also recruitment from all stages of differentiation and proliferation, including the pluripotent stem cell (CFU-GEMM) fraction; granulocyte-monocyte precursor cell (CFU-GM) fraction; and the fraction of juvenile granulocyte precursors cells capable of cell division, from myeloblasts to myelocytes. Based on the lymphocyte and monocyte overshoot, it was inferred that cells were recruited from mucosal lymphatic tissue, in addition to the lymph nodes, spleen, thymus, and bone marrow. These phenomena might play an important role in the mechanism that underlies the effectiveness of LCAP and the increased effectiveness of pulse LCAP, and it will be necessary to work to elucidate them. Moreover, it appears that investigating the clinical efficacy of pulse LCAP in patients who do not respond to conventional LCAP would be of major significance.

Leukocyte removal therapy for ulcerative colitis does not affect postoperative complications

BACKGROUND

We investigated the incidence of postoperative complications in patients treated with or without preoperative leukocyte removal therapy (LRT).

METHODS

The case notes of 387 patients with ulcerative colitis (UC) who underwent surgical intervention were retrospectively reviewed. One hundred nine patients were treated with LRT within 8 weeks before surgery (LRT group), and 278 had not received LRT since at least 8 weeks before surgery (without LRT group). We reviewed the postoperative complications according to type of initial operation.

RESULTS

Of the patients who underwent an ileal J-pouch anal anastomosis (IPAA) without an ileostomy, 3 (6.5%) in the LRT group developed pouch-related complications (PRC), while 11 (7.5%) in the without LRT group developed PRC. The overall postoperative complication rates were 28.3% in the LRT group and 21.8% in the without LRT group. For patients who underwent an IPAA with an ileostomy, the overall rates of postoperative complications were 39.1% in the LRT group and 31.8% in the without LRT group. Among those undergoing a total colectomy, 33.3% in the LRT group and 18.2% in the without LRT group had postoperative complications. No statistically significant differences were demonstrated between the two groups with respect to postoperative complications.

CONCLUSIONS

Our results suggest that preoperative LRT does not influence the rate of postoperative complications in UC patients.

Preliminary data on the use of apheresis in inflammatory bowel disease

In patients with inflammatory bowel disease (IBD), centrifugation has been attempted to remove leukocyte components from whole blood; however, the use of selective filters has proved to result in more active modification of cellular immunity in that 4 times as many white blood cells are removed, which may result in a greater therapeutic effect. Selective apheresis for treatment of IBD, in particular ulcerative colitis (UC), has been used in Japan and some European countries for several years; pilot studies with Adacolumn, a selective therapeutic granulocyte/monocyte apheresis device, in patients with IBD have recently been completed in the United States with favorable results. Unlike conventional pharmacological treatments, selective apheresis may be associated with a relatively low rate of adverse events. Multiple studies have suggested that selective apheresis may be of benefit as a steroid-sparing treatment. In an unblinded randomized trial in 69 steroid-dependent patients with active UC randomized to selective apheresis with Adacolumn or an increased dose of prednisolone, 83% of patients receiving Adacolumn achieved remission compared with 65% of those receiving an increased dose of prednisolone. In another uncontrolled study of 60 patients with active UC, treatment with Adacolumn selective apheresis enabled nearly 70% of steroid-dependent patients to discontinue prednisolone. An unblinded randomized controlled trial of a different selective apheresis device (Cellsorba) versus high-dose prednisolone in patients with active UC showed a greater therapeutic effect (74%) than high-dose prednisolone (38%) and lower frequency of adverse effects (24% versus 68%).

Leukocytapheresis therapy for steroid-naïve patients with active ulcerative colitis: its clinical efficacy and adverse effects compared with those of conventional steroid therapy

BACKGROUND

Steroid administration currently plays a central role in the medical management of ulcerative colitis (UC); however, long-term steroid usage causes adverse effects, which necessitates stoppage of drug intake, leading to worsening of the disease. A steroid-sparing, well-tolerated treatment is therefore required. As several investigators have reported the efficacy of leukocytapheresis (LCAP) combined with steroid therapy, we investigated the clinical usefulness and safety of LCAP for steroid-naïve patients with active UC for comparison with those of conventional steroid therapy.

METHODS

Twenty-nine Japanese patients with active UC without a history of steroid usage were selected to be treated with LCAP (n = 9) or prednisolone (PSL) (n = 20). LCAP administration continued for 10 weekly cycles. In the PSL group, patients with moderately severe disease received 0.5 mg/kg per day of PSL and those with severe disease 1.0 mg/kg per day. The PSL dosage was gradually tapered in accordance with improvement.

RESULTS

Eight (88.9%) of the LCAP group and 16 (80.0%) of the PSL group showed clinical improvement and three (33.3%) of the LCAP group and seven (35.0%) of the PSL group achieved remission. As for the treatment complications, three major adverse effects were observed in the PSL group, but none were observed in the LCAP group.

CONCLUSION

The results of this study suggest that the efficacy and safety of LCAP are equivalent, and in terms of severe adverse effects, superior to those of steroid therapy. LCAP therapy may thus be a promising candidate therapy for steroid-naïve patients with active UC.

Diminished cytokine signalling against bacterial components in mononuclear leucocytes from ulcerative colitis patients after leukocytapheresis

Infiltration by circulating inflammatory cells is a prominent local inflammatory feature of ulcerative colitis (UC). Several trials have suggested that leukocytapheresis by filtration can benefit patients with active UC. We investigated how this therapy might modulate the inflammatory response. Patients with active UC who were beginning repeated filtration leukocytapheresis were studied. Mononuclear cell preparations were obtained from blood before and after the first treatment, and expression of cytokine signalling components and the cell-proliferative response were analysed in vitro. Leukocytapheresis reduced lipopolysaccharide-induced production of proinflammatory cytokines (interleukin-1, -6, -8 and tumour necrosis factor-alpha, P < 0.05 for all) and activation of intracellular signalling components (nuclear factor-kappaB, mitogen-activated protein kinases, and signal transducer and activator of transcription-3), as well as surface expression of toll-like receptor-4 (P < 0.05) in mononuclear cells. The therapy also reduced the cell-proliferative response by mononuclear cells stimulated with sonicated bacterial preparations from autologous intestine (P < 0.05). These results indicate that activated mononuclear cells in the peripheral blood of patients with active UC are removed by leukocytapheresis and replaced by cells with a lower activation status. This replacement may partly explain the therapeutic benefit.

Leukocytapheresis Therapy Modulates Circulating T cell Subsets in Patients With Ulcerative Colitis

The aim of this study was to elucidate the molecular mechanisms responsible for the therapeutic effects of leukocytapheresis (LCAP). We investigated the alterations in circulating T cell subsets after LCAP therapy in ulcerative colitis (UC) patients. Eighteen patients with UC were enrolled. Fourteen patients were responders, and four patients were non-responders. Peripheral venous blood was obtained within 5 min before and 5 min after LCAP therapy. Flow cytometric analysis for T cell markers and intracellular interferon (IFN)-gamma (Th1) and interleukin (IL)-4 (Th2) was then performed. The average numbers of lymphocytes, T and B cells were significantly decreased after LCAP therapy, respectively (P < 0.01). The numbers of CD4+ and CD8+ T cells were also significantly decreased, respectively (P < 0.01), but the CD4+/CD8+ ratio was not changed. The number of CD45RO+ CD4+ memory T cells was significantly decreased. The number of CD25+ CD4+ T cells tended to decrease after LCAP therapy (not significant). However, the ratio of CD25+ CD4+-cells/CD25- CD4+-cells was significantly increased (P < 0.05). The number of IFN-gamma-positive (Th1) cells was significantly decreased after LCAP therapy, but there was no significant change in the number of IL-4-positive (Th2) cells. The Th1/Th2 ratio was significantly decreased after LCAP therapy. Some of the immuno-suppressive effects of LCAP therapy may be associated with a modulation of circulating T cell subsets.

Fluctuations in the peripheral blood leukocyte and platelet counts in leukocytapheresis in healthy volunteers

Leukocytapheresis (LCP) for the treatment of patients with diseases that involve an abnormal autoimmune reaction aims to improve the condition of the patient's pathology and to correct imbalances in immunological regulation mechanisms by removing the responsible leukocytes from the peripheral blood. To clarify the mechanism of therapeutic effect, LCP was conducted in healthy volunteers to investigate changes in peripheral blood leukocyte and platelet counts over time during the treatment. The subjects were 10 healthy male volunteers. LCP was performed once in each volunteer for 3,000 ml of blood volume. The peripheral blood counts decreased significantly, reaching a minimum of 20.0% of the baseline number of leukocytes, 10.1% of the baseline number of neutrophils, and 40.3% of the baseline number of lymphocytes. The number of removed leukocytes was about 6.6 x 10(9) cells, including about 3.5 x 10(9) neutrophils, as well as about 5.0 x 10(11) platelets. After the completion of LCP, the peripheral leukocyte levels increased transiently (overshoot), and at 2 h after the completion of the treatment, they reached 193.4% of the baseline value. Since LCP is capable of reducing the peripheral blood leukocyte count over a short period of time, its impact on peripheral blood is great. In addition, in view of the overshoot phenomenon and the appearance of immature granulocytes, the LCP may affect not only the peripheral blood, but also the bone marrow pool, the marginal pool, and the leukocytes present in the tissues.

Efficacy of the inflammatory cell infiltration inhibitor IS-741 on colitis induced by dextran sulfate sodium in the rat

We examined the therapeutic effects of the inflammatory cell infiltration inhibitor IS-741 (N-(2-((ethylsulfonyl)amino)-5-(trifluoromethyl)-3-pyridinyl)-cyclohexanecarboxamide monosodium salt monohydrate) on a rat colitis model. As a result of its effects on leukocyte infiltration, IS-741 inhibits cell adhesion, alleviates symptoms and signs of pancreatitis and multiple organ failure and demonstrates a life-saving effect in a model of severe acute pancreatitis. A rat model was prepared by inducing colitis with 3% dextran sodium sulfate (DSS) and maintaining pathology with 1% DSS. Repeated oral administration of IS-741 at 1, 10 or 100 mg/kg per day was conducted for 2 weeks (during treatment with 1% DSS). IS-741 at each dose decreased the area of erosion in the large intestine, thickening of the wall of the large intestine and anemia caused by melena. Some effects of IS-741 were nearly equivalent to those of the control compound salazosulfapyridine. Furthermore, IS-741 markedly alleviated inflammatory cell infiltration into the intestinal wall. IS-741 improved lesions in a rat DSS model by inhibiting leukocyte infiltration, suggesting the possibility of clinical application of this drug for IBD.