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.

Immunoadsorption therapy (therasorb) in patients with severe lupus erythematosus

Therapeutic removal of immune complexes and antibodies by plasmapheresis has been used in patients with systemic lupus erythematosus (SLE) since 1974. Modern methods of selective adsorption of immunoglobulins from the patient plasma (immunoadsorption, IAS) have been developed; they deserve to be investigated as a tool in the management of difficult cases of SLE. We report our experience in an uncontrolled series of five consecutive SLE patients, in whom cytotoxic immunosuppression was contraindicated or not sufficient to control the disease. Ig-Therasorb columns containing polyclonal sheep antihuman immunoglobulin antibodies were used for IAS for periods of 4 to 54 weeks. In order to prevent rebound autoantibody production, low doses of normal human immunoglobulin were substituted. Improvement in clinical and laboratory signs of disease activity was observed in all patients. In two patients the effect of cyclophosphamide therapy for lupus pneumonitis and lupus-associated thrombopenic purpura was consolidated. In three patients suffering from pancytopenia or lupus vasculitis, the use of cytotoxic substances could be avoided for more than a year. IAS seems to be a safe replacement of conventional plasmapheresis in difficult cases of severe lupus complications. Although controlled studies are lacking, this method may occupy a few important niches as an adjunct in managing immune complex mediated diseases.

Plasmapheresis and cyclophosphamide as successful treatments for pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an ulcerative skin disorder of unknown aetiology. We describe a 40-year-old woman with long-standing PG and who did not respond to the usual treatments; however, she was treated successfully with plasmapheresis followed by pulse intravenous cyclophospamide therapy.

Severe infections in plasmapheresis-treated systemic lupus erythematosus

OBJECTIVE

To assess the risk of infection in patients with systemic lupus erythematosus (SLE) treated with plasmapheresis in addition to intravenous (I.V.) pulse cyclophosphamide (CYC).

METHODS

We searched the records of all our SLE patients for those who had undergone plasmapheresis plus I.V. CYC treatment (n = 9). Consecutive patients with similarly high SLE activity who underwent I.V. CYC therapy but not plasmapheresis were included as controls (n = 12). We evaluated both groups for severe infections, outcome, and confounding clinical variables.

RESULTS

Seven of 9 plasmapheresis-treated patients had serious bacterial or viral infections, including 3 cases of cytomegalovirus infections. Among the 12 patients treated with I.V. CYC alone, only 2 had severe infections (P < 0.01). Three patients in the plasmapheresis group and none in the control group died of infections. Treatment efficacy, however, was similar for both groups.

CONCLUSION

Among SLE patients treated with plasmapheresis and I.V. CYC, life-threatening bacterial and viral infections and mortality occur more frequently than among patients with similarly active SLE treated with I.V. CYC alone.

Systemic lupus erythematosus with choroidopathy and serous retinal detachment

Systemic lupus erythematosus associated ocular manifestations usually consist of cotton-wool spots and retinal hemorrhages. The authors report one case of lupus choroidopathy revealed by bilateral serous retinal detachment, occurring 4 months after a systemic flare-up of the disease. An immune complexes-mediated phenomenon is involved in these manifestations, which are usually controlled by systemic corticosteroids and immunosuppressive agents. Plasma exchanges were successfully applied in this case, resulting in a disappearance of the retinal detachment in one month.