IgG immunoadsorption reduces systemic lupus erythematosus activity and proteinuria: a long term observational study

Effects of DNA Immunoadsorption Combined with Medication on Immune Function and Renal Function in Patients with Systemic Lupus Erythematosus

Objective. At present, glucocorticoids combined with cyclophosphamide are still used for the clinical treatment of systemic lupus erythematosus (SLE). However, long-term practice has shown that drug treatment currently has the phenomena of long treatment duration, uncontrollable conditions in a short period of time, and unsatisfactory efficacy. DNA immunoadsorption therapy is a newly developed therapy. The combination of drugs and DNA immunoadsorption has been reported for the treatment of SLEN in clinics for a long time. In this study, we observed the effects of DNA immunoadsorption combined with drug therapy on immune function and renal function in patients with systemic lupus erythematosus (SLE). The results showed that the DNA immunosorbent assay combined with medication in the treatment of SLE could quickly and specifically remove pathogenic substances from patients, improve renal function, immune function, and complement levels in patients, and help to relieve disease activity.

The development of immunosorbents for the treatment of systemic lupus erythematosus via hemoperfusion

Systemic lupus erythematosus (SLE) is an autoimmune disease (AID) that involves multiple organ systems and is characterized by elevated levels of autoantibodies (ANA) and immune complexes. The immunoadsorption technique uses an extracorporeal clearance process to remove pathogenic toxins from patients' blood and alleviate disease symptoms. An immunosorbent is a key component of the immunoadsorption system that determines therapeutic efficacy and safety. Immunosorbents are prepared by immobilizing antibodies, antigens, or ligands with specific physicochemical affinities on a supporting matrix. Immunosorbents and pathogenic toxins bind via affinity adsorption, which involves electrostatic interactions, hydrogen bonds, hydrophobic interactions, and van der Waals forces. Immunosorbents are classified on the basis of their interaction mechanism with toxins into three categories: non-selective, semi-selective, and highly selective. This review aimed to summarize the current status of various commercial immunosorbents that are used to treat SLE. Moreover, recent developments in immunosorbents have heightened the need for a brief discussion about specific ligands and a supporting matrix.

Therapeutic apheresis in kidney diseases: an updated review

Besides conventional medical therapies, therapeutic apheresis has become an important adjunctive or alternative therapeutic option to immunosuppressive agents for primary or secondary kidney diseases and kidney transplantation. The available therapeutic apheresis techniques used in kidney diseases, including plasma exchange, double-filtration plasmapheresis, immunoadsorption, and low-density lipoprotein apheresis. Plasma exchange is still the leading extracorporeal therapy. Recently, growing evidence supports the potential benefits of double-filtration plasmapheresis and immunoadsorption for more specific and effective clearance of pathogenic antibodies with fewer side effects. However, more randomized controlled trials are still needed. Low-density lipoprotein apheresis is also an important supplementary therapy used in patients with recurrent focal segmental glomerulosclerosis. This review collects the latest evidence from recent studies, focuses on the specific advantages and disadvantages of these techniques, and compares the discrepancy among them to determine the optimal therapeutic regimens for certain kidney diseases.

Protein A immunoadsorption combination with immunosuppressive therapy improves neuropsychiatric systemic lupus erythematosus: A case report

We described protein A immunoadsorption combination with immunosuppressive treatment improved rapidly a patient with Neuropsychiatric systemic lupus erythematosus.

Systemic Lupus Erythematosus (SLE) Therapy: The Old and the New

Despite recent improvements in the treatment of systemic lupus erythematosus (SLE), disease activity, comorbidities and drug toxicity significantly contribute to the risk of progressive irreversible damage accrual and increased mortality in patients with this chronic disease. Moreover, even lupus patients in remission often report residual symptoms, such as fatigue, which have a considerable impact on their health-related quality of life. In recent decades, SLE treatment has moved from the use of hydroxychloroquine, systemic glucocorticosteroids and conventional immunosuppressive drugs to biologic agents, of which belimumab is the first and only biologic agent approved for the treatment for SLE to date. Novel therapies targeting interferons, cytokines and their receptors, intracellular signals, plasma cells, T lymphocytes and co-stimulatory molecules are being evaluated. In the context of a holistic approach, growing evidence is emerging of the importance of correct lifestyle habits in the management of lupus manifestations and comorbidities. The aim of this paper is to provide an overview of current pharmacological and non-pharmacological treatment options and emerging therapies in SLE.

Acute pancreatitis and macrophage activation syndrome in pediatric systemic lupus erythematosus: case-based review

Pancreatitis is uncommon in systemic lupus erythematosus (SLE) and is rarely reported in children, possibly being related to macrophage activation syndrome (MAS). The incidence of MAS in children with lupus pancreatitis is unknown, as is their prognosis. In this case-based review, we report a pediatric patient with SLE complicated with pancreatitis and MAS, and performed a literature review. We report an 11-year-old girl with SLE and MAS who developed pancreatitis on the second day of methylprednisolone pulse therapy (500 mg/day). We continued methylprednisolone pulse therapy, and performed three rounds of DNA-immunoadsorption and three rounds of hemoperfusion. A second course of methylprednisolone pulse therapy was initiated 9 days later. The patient received a monthly cyclophosphamide pulse therapy (10 mg/kg/day, 2 consecutive days every month) for 6 months, after which she was treated with mycophenolate mofetil 20 mg/kg/day. The condition of the patient gradually improved, her blood amylase and lipase decreased. She was in a stable condition during 13-month follow-up period. Review of the literature of pediatric patients with SLE and pancreatitis showed that there are 127 cases that have been reported in the past 30 years, 40 cases were excluded in our study because of inadequate information. Of the 87 patients included in our literature review, the mortality rate was 33.33%, and 52.86% of the patients with pancreatitis had MAS at the same time. Pancreatitis is uncommon in SLE, but must be suspected if a patient with SLE develops digestive symptoms. Patients with SLE with pancreatitis have a high incidence of MAS and high mortality rate; however, early recognition and effective treatment can relieve the disease symptoms.

Blood purification in two patients with clinically amyopathic dermatomyositis associated with interstitial lung disease with anti-melanoma differentiation-associated gene-5 antibody (MDA-5)

Patients of clinically amyopathic dermatomyositis associated with rapidly progressive interstitial pneumonia (CADM-RFIP) with positive anti-MDA5 antibody usually presents rapid deterioration and traditional therapy such as cyclophosphamide combined with high-dose prednisone pulse therapy shows no clear benefit at whiles. However, blood purification combined with traditional therapy works according to the literature. We herein report two CADM-RFIP patients administered with DNA immunoadsorption combined with traditional therapy and then reviewed the literature of blood purification in CADM-RFIP patients at home and abroad to date. We emphasize blood purification such as DNA immunoadsorption could apply in the early stage of CADM-RFIP, which can decrease inflammation and allow us more time to control the condition better.

Refractory lupus nephritis: When, why and how to treat

Refractory lupus nephritis indicates an inadequate response to lupus nephritis therapy. It implies persisting or worsening disease activity despite therapy, but the definition is complicated by the parameters of response, proteinuria and renal function, that do not discriminate clearly between activity and irreversible damage. Understanding the causes of refractory disease and developing treatment strategies is important because these patients are more likely to develop poor outcomes, especially end stage renal disease. This review explores current concepts and definitions of refractory disease and summarises treatment approaches that have been used in observational cohort studies and case series. We highlight the importance of optimising adherence to the prescribed immunosuppressive and supportive measures and avoidance of diagnostic delay. Treatment options include higher dose glucocorticoid, switching between cyclophosphamide and mycophenolate acid derivates, or addition of rituximab, the latter potentially in combination with belimumab. Less evidence supports extracorporeal treatment (plasma exchange or immunoadsorption), calcineurin inhibitors (cyclosporine A or tacrolimus), intravenous immunoglobulin and stem cell transplantation. Improvements in understanding what refractory disease is and how definitions can be integrated into treatment pathways has the potential to enhance lupus nephritis outcomes.

M281, an Anti-FcRn Antibody: Pharmacodynamics, Pharmacokinetics, and Safety Across the Full Range of IgG Reduction in a First-in-Human Study

M281 is a fully human, anti-neonatal Fc receptor (FcRn) antibody that inhibits FcRn-mediated immunoglobulin G (IgG) recycling to decrease pathogenic IgG while preserving IgG production. A randomized, double-blind, placebo-controlled, first-in-human study with 50 normal healthy volunteers was designed to probe safety and the physiological maximum for reduction of IgG. Intravenous infusion of single ascending doses up to 60 mg/kg induced dose-dependent serum IgG reductions, which were similar across all IgG subclasses. Multiple weekly doses of 15 or 30 mg/kg achieved mean IgG reductions of ≈85% from baseline and maintained IgG reductions ≥75% from baseline for up to 24 days. M281 was well tolerated, with no serious or severe adverse events (AEs), few moderate AEs, and a low incidence of infection-related AEs similar to placebo treatment. The tolerability and consistency of M281 pharmacokinetics and pharmacodynamics support further evaluation of M281 in diseases mediated by pathogenic IgG.

Efficacy of plasma exchange and immunoadsorption in systemic lupus erythematosus and antiphospholipid syndrome: A systematic review

Extracorporeal treatments have been used since the 1970s in the management of systemic lupus erythematosus (SLE). A randomised controlled trial comparing the efficacy of standard of care (SOC) combined with plasma exchange against SOC alone in patients with lupus nephritis revealed no difference in terms of renal outcome. Subsequently, initial expectations have been dampened and further experience with plasma exchange is mainly limited to observational studies and single case reports. Beneficial effects have been reported in patients with refractory disease course or in pregnancy with prior complications due to SLE and antiphospholipid syndrome. A more specific form of extracorporeal treatment, immunoadsorption (IAS), has emerged as a valuable option in the treatment of SLE. In line with the plasma exchange experience, IAS seems to have beneficial effects in patients with refractory disease, contraindications to standard immunosuppression or during pregnancy. The mechanism IAS relates to autoantibody removal but for plasma exchange removal of activated complement components, coagulation factors, cytokines and microparticles may also be relevant. Both treatment forms have good safety profiles although reactions to blood product replacement in plasma exchange and procedure related complications such as bleeding or catheter-related infections have occurred. There is a need to more clearly define the clinical utility of plasma exchange and IAS in refractory lupus and APS subgroups.

Clinical efficacy comparison of HA280 and DNA280 immunoadsorption column in treating systemic lupus erythematosus

OBJECTIVE

The aim of this study was to compare the efficacy of HA280 and DNA280 immunoadsorption (IA) column in treating systemic lupus erythematosus (SLE), and provide the basis for seeking cost-effective solution for SLE.

METHODS

Fifty-seven severe SLE patients receiving IA treatment from January 2007 to December 2013 were selected. They were divided into HA280 group (31 cases) and DNA280 group (26 cases), which used HA280 and DNA280 IA column, respectively. The efficacy, adverse reactions, and hospitalization cost of the two groups were compared.

RESULTS

Both two groups could effectively reduce the SLE-associated antibodies, immunoglobulins, complement levels, serum creatinine, blood urea nitrogen, and 24-h urine protein levels (P < 0.05). The efficiency and incidence of adverse reactions of two groups were similar (P > 0.05), while the hospitalization cost of HA280 group was significantly less than that of DNA280 group (P < 0.05).

CONCLUSIONS

Application of HA280 IA column in IA treatment is relatively the most cost-effective adjuvant therapy to severe SLE.

Fibrinogen reduction and bleeding complications in plasma exchange, immunoadsorption and a combination of the two

BACKGROUND

Immunoadsorption (IAS) and therapeutic plasma exchange (TPE) are considered safe although fibrinogen is removed. To date no comparison of fibrinogen reduction and associated risk of bleeding in apheresis exists.

METHODS

Retrospective analysis of TPE, three IAS adsorbers, and combined TPE/IAS regarding fibrinogen reduction and bleeding incidence in 67 patients (1,032 treatments).

RESULTS

TPE and TPE/IAS reduced fibrinogen by 64 ± 11% and 58 ± 9%, leading to concentrations <100 mg/dl in 20 and 17% of treatments, respectively. IAS decreased fibrinogen less than TPE (26 ± 6%, p < 0.0001), resulting in fibrinogen concentrations <100 mg/dl in 1% of treatments. The processed volume correlated with reduction in TPE (r = 0.64, p < 0.01), but not in IAS. Bleeding occurred in 1.3% (IAS), 2.3% (TPE) and 3.1% (TPE/IAS) of treatments.

CONCLUSION

Hypofibrinogenemia occurs in 20% of patients after TPE and TPE/IAS, but rarely after IAS. IAS removes fibrinogen independently of volume processed. Overall, bleeding is rare in apheresis.

The selective therapeutic apheresis procedures

Selective apheresis procedures have been developed to target specific molecules, antibodies, or cellular elements in a variety of diseases. The advantage of the selective apheresis procedures over conventional therapeutic plasmapheresis is preservation of other essential plasma components such as albumin, immunoglobulins, and clotting factors. These procedures are more commonly employed in Europe and Japan, and few are available in the USA. Apheresis procedures discussed in this review include the various technologies available for low-density lipoprotein (LDL) apheresis, double filtration plasmapheresis (DFPP), cryofiltration, immunoadsorption procedures, adsorption resins that process plasma, extracorporeal photopheresis, and leukocyte apheresis.

Double filtration plasmapheresis in different diseases in Thailand

Double filtration plasmapheresis (DFPP) was applied to the treatment of two different categories from 100 cases that had been collected over a 5 year period (2007-2011). These categories were allocated into groups by size of toxic substances, which were classified as two different kinds of diseases. Group I comprised diseases that were caused by alloimmunity in transplantation, autoimmune diseases, complicated nephrotic syndrome, pure red cell aplasia, and toxemia of pregnancy. This group was treated with a plasma separator (plasmaflow-05, Asahi Kasei) and plasma fractionators, EC-20W. The second group, which included hyperviscosity syndrome, was treated by the same plasma separator, but with different plasma fractionators using EC-40W. This group included diabetes nephropathy, hyperlipidemia, peripheral arterial diseases, and neurosensory hearing loss. Both groups used 1.5 plasma volumes in each treatment for three sessions in two consecutive weeks. The result of treatment in group I showed that plasma immunoglobulin G (IgG) was decreased substantially by 66% in either transplant or lupus nephritis patients after the third session. In the second group, IgM, fibrinogen, and lipid markedly responded to the treatment. Two diabetes nephropathy patients showed stable renal function for more than 12 months. Peripheral arterial disease was shown to benefit from significantly decreasing fibrinogen and IgM, which resulted in clinical tissue oxygenation. Neither bleeding diathesis nor membrane anaphylaxis were reported from the treatment. In summary, apheresis patients were shown to benefit in hypersensitized and hyperviscosity syndrome.

Unexpected recovery from longterm renal failure in severe diffuse proliferative lupus nephritis

Background

Severe renal manifestation of systemic lupus erythematosus (SLE) is not uncommon and is associated with an indeterminate prognosis. Complete remission can be obtained, however, at least in the young when chronic lesions are absent and adequate anti-inflammatory therapy is immediately initiated.

Case presentation

We report the unusual case of a 12-year-old girl who presented with severe oliguric renal failure, macrohematuria and skin rash. Renal biopsy revealed the diagnosis of severe diffuse proliferative glomerulonephritis (GN) with cellular crescents in 15 out of 18 glomeruli and full-house pattern in immunofluorescence indicating lupus nephritis IVB according to WHO, IV-G(A) according to ISN/RPS classification. The serological parameters confirmed the diagnosis of SLE and the patient was immediately treated with methylprednisolone, cyclophosphamide and immunoadsorption. Initially, despite rapid amelioration of her general condition, no substantial improvement of renal function could be achieved and the patient needed hemodialysis treatment for 12 weeks. Unexpectedly, in the further follow-up at first diuresis increased and thereafter also creatinine levels substantially declined so that hemodialysis could be discontinued. Today, 6 years after the initial presentation, the patient has normal renal function and a SLEDAI score of 0 under a continuous immunosuppressive therapy with Mycophenolate mofetil (MMF) and low dose steroid.

Conclusion

Despite the severity of the initial renal injury and the unfavourable renal prognosis the kidney apparently has a tremendous capacity to recover in young patients when the damage is acute and adequate anti-inflammatory therapy is initiated without delay.

Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis

OBJECTIVES

To develop recommendations for the management of adult and paediatric lupus nephritis (LN).

METHODS

The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus.

RESULTS

Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults.

CONCLUSIONS

Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.

Accelerated recovery from nephrotic syndrome with acute renal failure by double filtration plasmapheresis in a patient with lupus podocytopathy

We describe a case of an adult female who presented with nephrotic syndrome. She was diagnosed with systemic lupus erythematosus with serum antinuclear antibodies, leucopenia with lymphopenia, butterfly erythema, and nephrotic syndrome. Renal biopsy revealed normal glomeruli with diffuse effacement of the foot processes, consistent with lupus podocytopathy. Although human albumin replacement was performed initially, acute renal failure developed rapidly. Therefore, she was treated with double filtration plasmapheresis (DFPP) in addition to oral steroid. After steroid therapy combined with DFPP, the renal function and proteinuria improved rapidly. Although the impact of DFPP on the treatment of lupus nephritis remains to be delineated, our observations suggest that DFPP in lupus podocytopathy played a pivotal role in facilitating the early recovery from renal injuries. Because of the rapid improvement of renal function without any change in body weight by DFPP, acute renal failure in the setting of lupus podocytopathy might contribute to an alternative pathophysiological factor for the diminished glomerular filtration rate, similar to that observed in the setting of idiopathic minimal change glomerulopathy.

Successful treatment of thromboangiitis obliterans (Buerger's disease) with immunoadsorption: results of a pilot study

BACKGROUND

No established therapy is available for patients with thromboangiitis obliterans (TAO) and critical limb ischemia. Since abnormalities of the immune system appear to be involved in the pathogenesis, we investigated in this pilot study the efficiency of Ig immunoadsorption (IA) therapy.

METHODS

Ten patients with advanced TAO underwent a single IA course over five consecutive days. Before IA angiography was performed. In addition, the following were conducted prior to IA, directly after, as well as 1, 3, and 6 months after IA: clinical examination, pain scale (0-10), treadmill test for evaluation of maximum walking distances, and several angiological methods for evaluation of disease extent: photoplethysmography, ultrasound Doppler, and transcutaneous assessment of partial carbon dioxide (tcPCO(2)) and oxygen (tcPCO(2)) pressure.

RESULTS

Immunoadsorption treatment was tolerated without side effects. Pain intensity decreased rapidly from 7.7 ± 0.8 (mean ± SEM) before treatment to 2.0 ± 1.2 at the second day of IA. One month after IA, all patients were without pain. This functional amelioration persisted over the follow-up period of 6 months. Correspondingly, maximum walking distances significantly increased from 301.7 ± 191.4 to 727.0 ± 192.7 m immediately after IA, and further continuously up to 1,811.0 ± 223.7 at 6 months after IA. Healing of ischemic ulcerations was observed in all patients during follow-up. (tcPCO(2)) and (tcPCO(2)) values as well as photopletysmographic data that were severely compromised before IA reflecting reduced tissue oxygenation and perfusion showed rapid amelioration reaching normal values at 1 month.

CONCLUSION

Anti-Ig IA appears to be an effective therapeutic option for patients with advanced TAO.

Immunoadsorption (IAS) for systemic lupus erythematosus

Immunoadsorption (IAS) is used as a rescue therapy in severely ill SLE patients who are refractory to conventional therapies. This extracorporeal method aims at the rapid and extensive removal of pathogenic immunocomplexes (ICs) and (auto-)antibodies (Abs). Although past data have shown short- to mid-term efficacy and biocompatibility of IAS in (renal) SLE, it is still an experimental and rather expensive procedure – and evidence from randomized controlled trials (RCTs) is lacking. Nevertheless, IAS is successfully used in life-threatening situations because of its fast mode of action and its acceptable safety profile.

Pathogenetic aspects of systemic lupus erythematosus with an emphasis on regulatory T cells

The development of autoimmune diseases is characterized by the breakdown of mechanism(s) that are responsible for maintaining immunological tolerance against self-structures in the periphery. Several aberrations of immune cells have been described so far. Most recently quantitative and/or qualitative defects of T cells with the capacity to suppress or regulate the proliferation of effector T cells in vitro - subsequently termed regulatory T cells (Treg) - have been suggested to substantially contribute to the imbalance of peripheral tolerance and trigger the outbreak of autoimmune reactions. The aim of this article is to summarize current knowledge about pathomechanisms that are involved in the development of autoimmunity with a special emphasis on the role of Treg in patients with systemic lupus erythematosus (SLE).

Preparation of affinity sorbents with immobilized synthetic ligands for therapeutic apheresis

Preparation and stability of a few examples of medical sorbents are described. A simple and practical technique has been developed for sorbent preparation with the low weight synthetic ligands such as amino acids, peptides or oligosaccharides. This approach to sorbent preparation enables the development of the new affine columns generation for medicine and biotechnology to be carried out with ease.

Lupus nephritis

Lupus nephritis (LN) is one of the common manifestations of systemic lupus erythematosus. Kidney biopsy remains a mainstay of LN diagnosis, which is usually prompted by abnormal urinary sediment, proteinuria, or elevated creatinine. New International Society of Nephrology/Renal Pathology Society classification of LN tends to remove some of the ambiguities of World Health Organization classification and results in better categorization of patients. Although prognosis of LN has improved with the combined use of cytotoxic and steroid therapy, up to 20% of these patients progress to renal failure. Moreover, toxicity of the current regimens remains a major concern. Last few decades have seen a tremendous progress being made in understanding the pathogenesis of LN, but a little has been added to armamentarium against LN, leaving physicians with a few choices. Fortunately, with unfolding of molecular processes involved in disease pathogenesis, new targets for drug therapy have emerged. Whether these medications will prove to be more efficacious and less toxic remains a matter of debate and will be answered by several ongoing trials and future studies.

Efficacy and safety of TNF-blocker therapy in systemic lupus erythematosus

BACKGROUND

There is still unmet medical need in the therapy of severe organ manifestations of patients with systemic lupus erythematosus (SLE). Therapeutic agents targeting pro-inflammatory cytokines may be an interesting option.

OBJECTIVE

To review available data on the efficacy and safety of tumour necrosis factor (TNF) blockade in SLE.

METHODS

A review of the literature was conducted.

RESULTS/CONCLUSIONS

Open-label experience suggests that TNF blockade is effective in SLE patients with arthritis, nephritis and skin disease. In particular, nephritis may remain in long-term remission after just four infusions of infliximab administered. Despite the induction of lupus-specific autoantibodies, short-term therapy with infliximab in combination with azathioprine appears feasible and relatively safe. The data call for controlled clinical trials, at least one of which has been initiated.

IdeS: a bacterial proteolytic enzyme with therapeutic potential

Background

IdeS, a proteinase from Streptococcus pyogenes, cleaves immunoglobulin (Ig)G antibodies with a unique degree of specificity. Pathogenic IgG antibodies constitute an important clinical problem contributing to the pathogenesis of a number of autoimmune conditions and acute transplant rejection. To be able to effectively remove such antibodies is therefore an important clinical challenge.

Methodology/Principal Findings

IdeS was found to specifically and efficiently cleave IgG in human blood in vitro (20 µg of IdeS caused a complete degradation of IgG in one ml of human whole blood in 15 minutes) and to clear IgG from the blood stream of rabbits in vivo (no IgG was detected six hours following an intravenous injection of 5 mg of IdeS) without any side effects. In a mouse model of immune thrombocytopenic purpura (ITP), polyclonal IgG antibodies against platelet surface antigens were used to induce a lethal disease. These profoundly thrombocytopenic animals were treated and cured by a single injection of IdeS.

Conclusions/Significance

Novel information is provided concerning the IgG-cleaving activity of IdeS in vitro and in vivo. The highly specific and rapid elimination of IgG in vivo, the dramatic effect in a mouse model of ITP, and the lack of side effects in the treated animals, indicate that IdeS could also be used to treat IgG-driven diseases in humans.

Recommendations for the use of immunoapheresis in the treatment of autoimmune bullous diseases

Despite the use of high-dose systemic corticosteroids in combination with other immunosuppressants, in some patients with autoimmune bullous diseases only insufficient improvement is achieved. In these cases and in acute severe disease, adjuvant immunoapheresis has been increasingly used. A consensus meeting was held in mid-2005 in Hamburg, aiming at developing guidelines for the use of immunoapheresis in the treatment of autoimmune bullous diseases. This paper summarizes the experts' recommendations.

[Systemic lupus erythematosus--activity and outcome]

Both clinically and scientifically, the variable organ manifestations of systemic lupus erythematosus (SLE) pose a particular challenge to rheumatologists. Validated scores for disease activity (BILAG, ECLAM, SIS, SLAM, SLEDAI), damage (SLICC/ACR damage index) and health-related quality of life (MOS SF-36) have been successfully used for years. New therapies, however, need to show improvement on outcome parameters for defined organ systems--and these are mostly ill-defined. For proliferative lupus nephritis, well designed studies have been available for years. However, these use very severe outcome parameters (renal failure, death), and therefore take at least 5 years for definitive results. Of the surrogate markers which were devised, none has proven reliable for determining outcome. The combination of shorter studies for defining hopeful strategies followed by long definitive studies, appears to be the best option at present.

Plasma exchange for systemic lupus erythematosus

Efficacy of plasma exchange in patients with systemic lupus erythematosus has not been supported by the results of the first non-controlled and retrospective studies. Nonetheless, they remain relevant for some selected patients with life-threatening manifestations and/or severe therapy-resistant manifestations. They can be used as an adjuvant therapy in combination with corticosteroids and, when required, other immunosuppressant(s) for refractory renal disease, alveolar hemorrhage, some neuropsychiatric manifestations, thrombotic thrombocytopenic purpura, catastrophic antiphospholipid syndrome, hyperviscosity syndrome or symptomatic cryoglobulinemia. The use of newer technologies, like immunoadsorption, possibly in combination with recent biologics, might, in the future, offer some new perspectives for extracorporeal therapy of systemic lupus erythematosus.

Pathogenesis and treatment of systemic lupus erythematosus nephritis

PURPOSE OF REVIEW

Glomerulonephritis is a challenging complication of systemic lupus erythematosus that still results in kidney loss in up to 30% of patients. In this review we highlight the development of integrated efforts to link pathogenesis with disease definition and new therapeutics.

RECENT FINDINGS

Immune complex deposition in the kidney initiates an inflammatory cascade that causes glomerular disease but there are many modulating factors including genetic predisposition, products of the innate immune system, cytokines, complement and activated cells (both renal and immune). Animal models can help dissect potential disease mechanisms but the study of multiple models will be required since there are multiple subsets of human disease. Recent therapeutic studies in humans address the distinction between therapies for remission induction and remission maintenance. Multiple studies confirm the therapeutic equivalence of mycophenolate mofetil and cyclophosphamide in induction of remission but results are still far from ideal. The next few years should see the testing of new biologic reagents in humans. Another area of interest is the search for noninvasive measures of disease and disease response.

SUMMARY

Although there has been remarkable progress in our understanding of the immunology and phenotype of lupus nephritis current therapies have insufficient efficacy. As new therapies emerge, improved clinical design coupled with mechanistic studies will be needed to identify agents that may be effective only in some patient subpopulations.

Therapeutic options for resistant lupus nephritis

OBJECTIVES

To summarize the therapeutic options for proliferative and membranous lupus nephritis that is resistant to conventional treatment.

METHODS

Treatment trials in human lupus nephritis from years 1985 to 2005 that have been published in the English literature were searched by Medline using the keywords "lupus," "nephritis," "glomerulonephritis," "renal," "refractory," "resistant," "recalcitrant," "cyclophosphamide," "mycophenolate," "cyclosporin," "tacrolimus," "leflunomide," "intravenous immunoglobulin," "apheresis," "plasmapheresis," "immunoadsorption," "marrow transplantation," "stem cell transplantation," "immunoablative," "rituximab," and "biologics." Laboratory, histological, and nonrenal lupus studies were excluded.

RESULTS

There is no universal definition of treatment resistance in lupus nephritis. Controlled trials in refractory lupus nephritis are largely unavailable. Open-labeled studies have reported success of newer immunosuppressive drugs, immunomodulatory therapies, and the biological agents such as mycophenolate mofetil (MMF), calcineurin inhibitors, leflunomide, intravenous immunoglobulin, immunoadsorption, and rituximab in the treatment of cyclophosphamide (CYC) resistant proliferative lupus nephritis. More aggressive CYC regimens have been used in lupus nephritis, but at the expense of more toxicities. For membranous lupus nephritis (MLN), a combination of corticosteroids with either azathioprine, chlorambucil, cyclosporin A, MMF, or CYC is initially effective in two-thirds of patients. More aggressive and costly regimens should be reserved for truly refractory disease with persistent nephrotic syndrome or declining renal function. Evidence regarding the efficacy of MMF in refractory MLN is conflicting and controlled trials are necessary to resolve the controversy.

CONCLUSIONS

The treatment of refractory lupus nephritis remains anecdotal. An international consensus in the renal response criteria should be developed and validated so that controlled trials can be performed to compare the efficacy of various treatment modalities.

Prolonged Clinical Remission of Patients with Severe Pemphigus upon Rapid Removal of Desmoglein-Reactive Autoantibodies by Immunoadsorption

BACKGROUND

In pemphigus, loss of epidermal adhesion is induced by binding of circulating autoantibodies to the desmosomal cadherins desmoglein 3 (Dsg3) in pemphigus vulgaris (PV) and desmoglein 1 (Dsg1) in pemphigus foliaceus (PF), respectively. Therapeutic removal of Dsg-reactive autoantibodies by immunoadsorption (IA) has been demonstrated to exert clinical remission of the disease.

OBJECTIVES

The aim of this intervention study was to evaluate the efficacy and safety of the peptide-based Globaffin adsorber system in the treatment of severe pemphigus cases.

PATIENTS AND METHODS

We applied IA in 4 PV and 2 PF patients with severe chronic disease resistant to conventional immunosuppressive therapy. IA was performed on 4 consecutive days, representing 1 treatment cycle, followed by a 4-week treatment-free interval. Serum samples for determining serum IgG and anti-Dsg1/Dsg3 IgG autoantibodies were drawn daily before and after IA, respectively. During follow-up, patients were examined carefully, and laboratory parameters were controlled monthly for up to 1 year.

RESULTS

IA led to excellent clinical responses. Skin and mucosal lesions cleared almost completely within weeks. One IA cycle reduced anti-Dsg1 and anti-Dsg3 autoantibodies by an average of 50-70% as determined by ELISA.

CONCLUSIONS

Using the Globaffin adsorber system, IA represents an effective and safe treatment opportunity in severe and therapy-resistant pemphigus.

The Course of Anticardiolipin Antibody Levels Under Immunoadsorption Therapy

BACKGROUND

The emergence of anticardiolipin antibodies in patients with systemic lupus erythematosus is a serious occurrence in regard to a high risk for thrombosis and thromboembolic complications, fetal loss, and renal insufficiency. In an observational analysis, we studied anticardiolipin antibodies during immunoadsorption therapy.

METHODS

We analyzed the magnitude and time course of serum concentrations of the immunoglobulin G (IgG) and IgM subtypes of anticardiolipin antibodies (CIgG and CIgM) along with IgG and IgM, antinuclear antibodies, and antibodies to double-stranded DNA before and after single immunoadsorption sessions and their long-term course in 11 patients with systemic lupus erythematosus.

RESULTS

Single immunoadsorption sessions (n = 842) led to a rapid decline in CIgG and CIgM levels by 62.94% +/- 21.60% and 42.02% +/- 22.14%, respectively (P < 0.0001), along with a corresponding decline in serum levels of antinuclear antibodies (65.04% +/- 18.83%), antibodies to double-stranded DNA (64.67% +/- 21.20%), IgG (58.11% +/- 16.84%), and IgM (32.15% +/- 15.58%). Reduction rates of CIgG and CIgM levels were greater when high initial concentrations (P < 0.0001) and low IgG levels (P < 0.0001) were present. Mean reductions in pretreatment values of CIgG and CIgM during 6 months of immunoadsorption therapy were 42.85% +/- 39.94% and 29.39% +/- 70.41% (mean number of sessions/patient = 21.55) and for the 1-year period were 63.20% +/- 22.49% and 58.05% +/- 40.16% (mean number of sessions/patient = 30.46).

CONCLUSION

We observed that immunoadsorption therapy is an effective method to reduce anticardiolipin antibody levels rapidly and keep them at a low level in the long term.