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Leukocytapheresis in patients with inflammatory bowel diseases. GASTROENTEROLOGY REVIEW 2021; 6:99-105. [PMID: 34276835 PMCID: PMC8275965 DOI: 10.5114/pg.2021.106658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 06/30/2020] [Indexed: 11/17/2022]
Abstract
Leukocytapheresis, a blood purification therapy, exerts anti-inflammatory effects by removing activated leukocytes from the peripheral blood through extracorporeal circulation. It is a potential option of treatment for patients with inflammatory bowel diseases (IBD), especially those with ulcerative colitis (UC), who do not respond to conventional therapy. Given that it has a favourable safety profile and seems to have steroid sparing effects, its position in the treatment of UC is likely to expand. However, there is inadequate evidence to draw any conclusions about the efficacy of leukocytapheresis in patients with Crohn's disease, and it should only be used in accordance with special arrangements for consent. Considering the current level of knowledge, it is essential to conduct large, well-designed, randomized clinical trials to evaluate the effects of leukocytapheresis in the management of IBD patients.
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Chen XL, Mao JW, Wang YD. Selective granulocyte and monocyte apheresis in inflammatory bowel disease: Its past, present and future. World J Gastrointest Pathophysiol 2020; 11:43-56. [PMID: 32435521 PMCID: PMC7226913 DOI: 10.4291/wjgp.v11.i3.43] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/05/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023] Open
Abstract
The etiology and pathogenesis of inflammatory bowel disease (IBD), including ulcerative colitis and Crohn’s disease, are not fully understood so far. Therefore, IBD still remains incurable despite the fact that significant progress has been achieved in recent years in its treatment with innovative medicine. About 20 years ago, selective granulocyte and monocyte apheresis (GMA) was invented in Japan and later approved by the Japanese health authority for IBD treatment. From then on this technique was extensively used for IBD patients in Japan and later in Europe. Clinical trials from Japan and European countries have verified the effectiveness and safety of GMA therapy in patients with IBD. In 2013, GMA therapy was approved by China State Food and Drug Administration for therapeutic use for the Chinese IBD patients. However, GMA therapy has not been extensively used in China, although a few clinical studies also showed that it was effective in clinical and endoscopic induction of remission in Chinese IBD patients with a high safety profile. This article reviews past history, present clinical application as well as the future prospective of GMA therapy for patients with IBD.
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Affiliation(s)
- Xiu-Li Chen
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Jing-Wei Mao
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Ying-De Wang
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
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Cytapheresis (CAP) with leukocyte removal filter/bead column as one therapeutic option for inflammatory bowel disease. Transfus Apher Sci 2017; 56:689-697. [PMID: 28986009 DOI: 10.1016/j.transci.2017.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inflammatory bowel disease (IBD) like Crohn's disease and ulcerative colitis are chronic inflammatory disorders that affect the bowel. The disease is characterized by periods of clinical remission and relapse due to severe intestinal inflammation. Drug therapy of IBD is associated with unpleasant side effects. Further, efficacies of conventional drugs decrease with chronic use and this can represent a major difficulty in the long term management of IBD. However, in active IBD, leukocytes are elevated in the lesion they may be able to be a factor of IBD aggravation. Membrane filters column and leukocyte adsorbing beads have been developed which are direct blood perfusion systems for removing any desired level of leukocytes. Clinical studies with these two new models have shown good effects for active IBD. Clinical data suggest that leukocytapheresis might be an effective adjunct to therapy of IBD, to promote remission, taper conventional drug dosage and potentially should reduce the number of patients who require colectomy. The results may further understandings of the pathophysiology of IBD and this in turn should contribute to a more effective treatment of this disorder.
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Fowler S, Jones J, Hull PR, Ghosh S. Extracorporeal photopheresis for the treatment of Crohn's disease. Transfus Apher Sci 2015; 52:183-6. [DOI: 10.1016/j.transci.2015.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Törüner M, Toprak SK, Mızrak K, Yıldırım Y, Bay M, Ayyıldız E, Ilhan O. Adsorptive Leukocytapheresis in Inflammatory Bowel Diseases: Our Preliminary Results are Encouraging. TURKISH JOURNAL OF HAEMATOLOGY : OFFICIAL JOURNAL OF TURKISH SOCIETY OF HAEMATOLOGY 2014; 30:219-20. [PMID: 24385792 PMCID: PMC3878464 DOI: 10.4274/tjh.2012.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/22/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Murat Törüner
- Ankara University, School of Medicine, Department of Gastroenterology, Ankara, Turkey
| | - Selami Koçak Toprak
- Başkent University, School of Medicine, Department of Hematology, Ankara, Turkey
| | - Kiraz Mızrak
- Ankara University, School of Medicine, Department of Hematology, Therapeutic Apheresis Unit, Ankara, Turkey
| | - Yasin Yıldırım
- Ankara University, School of Medicine, Department of Hematology, Therapeutic Apheresis Unit, Ankara, Turkey
| | - Meltem Bay
- Ankara University, School of Medicine, Department of Hematology, Therapeutic Apheresis Unit, Ankara, Turkey
| | - Erol Ayyıldız
- Ankara University, School of Medicine, Department of Hematology, Therapeutic Apheresis Unit, Ankara, Turkey
| | - Osman Ilhan
- Ankara University, School of Medicine, Department of Hematology, Therapeutic Apheresis Unit, Ankara, Turkey
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Sands BE, Katz S, Wolf DC, Feagan BG, Wang T, Gustofson LM, Wong C, Vandervoort MK, Hanauer S. A randomised, double-blind, sham-controlled study of granulocyte/monocyte apheresis for moderate to severe Crohn's disease. Gut 2013; 62:1288-94. [PMID: 22760005 DOI: 10.1136/gutjnl-2011-300995] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Activated granulocytes and monocytes may contribute to the pathogenesis of Crohn's disease (CD). In small, uncontrolled studies, granulocyte/monocyte apheresis (GMA) has shown promise in treating CD. We conducted a randomised, double-blind study to compare GMA with a sham procedure in patients with moderate to severe CD. DESIGN Patients with active CD as defined by a Crohn's Disease Activity Index (CDAI) of 220-450 were randomly allocated in a 2:1 ratio to treatment with GMA using the Adacolumn Apheresis System (JIMRO, Takasaki, Japan) or sham apheresis. Ten apheresis sessions were scheduled over a 9-week period, and efficacy was evaluated at week 12. The primary end point was the proportion of patients achieving clinical remission (CDAI score ≤ 150 without use of prohibited drugs). RESULTS Clinical remission was achieved by 17.8% of patients in the GMA group (n = 157) compared with 19.2% of those in the sham control group (n = 78) (absolute difference--1.4% (95% CI--12.8% to 8.5%), p = 0.858). Clinical response (defined as a ≥ 100-point decrease in CDAI) was achieved by 28.0% and 26.9% of patients in the GMA and sham groups, respectively (p = 1.000). The two treatments produced similar changes from baseline in CDAI and quality of life, as well as in disease severity assessed endoscopically. The incidence and types of adverse events did not differ between groups. CONCLUSIONS GMA was well tolerated, but this study did not demonstrate its effectiveness over a sham procedure in inducing clinical remission or response in patients with moderate to severe CD.
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Affiliation(s)
- Bruce E Sands
- Division of Gastroenterology, Mount Sinai Medical Center and Mount Sinai School of Medicine, New York, NY 10029, USA.
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Kobayashi T, Mitsuyama K, Yamasaki H, Masuda J, Takedatsu H, Kuwaki K, Yoshioka S, Nagayama K, Sata M. Microarray analyses of peripheral whole blood cells from ulcerative colitis patients: effects of leukocytapheresis. Int J Mol Med 2013; 31:789-96. [PMID: 23403617 DOI: 10.3892/ijmm.2013.1270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 12/05/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Teppei Kobayashi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
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Fukunaga K, Matsumoto T. Current status and future perspectives of leukocytapheresis for inflammatory bowel disease. J Gastroenterol Hepatol 2012; 27:997-1003. [PMID: 22414250 DOI: 10.1111/j.1440-1746.2012.07119.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) comprise the idiopathic inflammatory bowel diseases (IBD) of the gut. The etiology of IBD is poorly understood, but an autoimmune disturbance has been suggested to play an important role in this incurable disease. Extracorporeal leukocytapheresis (CAP) is an additional adjunct for IBD patients refractory to other conventional therapies, including steroids. The primary aim of CAP should be to suppress such unwanted immunological response by removing circulating inflammatory cells from the blood stream. The first decade has been passed since CAP was approved by Japanese social health insurance policy. It is therefore now an appropriate opportunity to upgrade and summarize our current understandings and/or future perspectives of this unique non-pharmacological and non-surgical strategy for IBD patients. According to several clinical and basic research reports, an early introduction of CAP should produce higher efficacy as compared with CAP applied sometime after a clinical relapse. Likewise, CAP therapy adjusted to patients' body-weight as well as two treatment sessions per week (intensive regimen) should benefit the efficacy rate. The etiology of IBD is not fully elucidated yet. As a result, the major therapeutic strategies in the Western world have been immunosuppressive therapy, including biologics. CAP is an unusual treatment modality for IBD because it seems to have both effectiveness and safety, which should generally be balanced in this type of illness. We now have to develop future strategies with and without combining biologics to improve the quality of life of IBD patients.
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Affiliation(s)
- Ken Fukunaga
- Departments of Lower Gastroenterology and Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Optimal apheresis treatment volume for the efficacy and safety of leukocytapheresis with cellsorba in patients with active ulcerative colitis. J Clin Apher 2011; 26:326-31. [DOI: 10.1002/jca.20314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 10/05/2011] [Indexed: 12/25/2022]
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Mitsuyama K, Sata M. Therapeutic leukocytapheresis in inflammatory bowel disease: clinical efficacy and mechanisms of action. Cytotherapy 2009; 11:229-37. [PMID: 19241197 DOI: 10.1080/14653240902725566] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Keiichi Mitsuyama
- Department of Medicine, Kurume University School of Medicine, Japan.
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Mitsuyama K, Andoh A, Masuda J, Yamasaki H, Kuwaki K, Takedatsu H, Seki R, Nishida H, Tsuruta O, Sata M. Mobilization of bone marrow cells by leukocytapheresis in patients with ulcerative colitis. Ther Apher Dial 2008; 12:271-7. [PMID: 18789113 DOI: 10.1111/j.1744-9987.2008.00587.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Keiichi Mitsuyama
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
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12
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Matsumoto T, Fukunaga K, Kamikozuru K, Tozawa K, Yokoyama Y, Kusaka T, Onishi K, Miwa H, Nakamura S. Cytapheresis as a Non-Pharmacological Therapy for Inflammatory Bowel Disease. Transfus Med Hemother 2007; 35:18-23. [PMID: 21547106 DOI: 10.1159/000111763] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 10/09/2007] [Indexed: 01/01/2023] Open
Abstract
SUMMARY: Although inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), is a chronic recurrent disease with unknown etiology. Recent immunological studies suggest close relation to autoimmune status featured by antibodies against colonic epithelial cells. For patients with IBD, 5-aminosalycilates are often used in case of mild disease, and corticosteroids are standard therapy for moderate-to-severe disease. However, we often encounter patients who are resistant to or dependent of conventional therapy, which are likely to lead to future problems in quality of life due to adverse effects of drugs used, especially corticosteroids. Extracorporeal leukocyte removal therapy (cytapheresis) is one of the adjunctive therapies for IBD patients refractory to steroids. By removing circulating activated leukocytes, especially granulocytes and lymphocytes, impaired immune response is suppressed. In the present article recently published studies are reviewed in order to reflect the current state of the art in the use of cytapheresis for treating IBD, especially UC and CD. Although there are only few randomized controlled trials, clinical experience so far suggests that cytapheresis has superior efficiency than conventional therapies in steroid-resistant moderate-to-severe UC. Moreover, cytapheresis features its safety characteristic compared with other conventional medications for severe UC, cytapheresis is regarded as safe treatment regimen.
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Affiliation(s)
- Takayuki Matsumoto
- Division of Lower Gl Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Abstract
The etiology of inflammatory bowel disease (IBD) is not completely understood, thus current therapies have been empirical and directed at treating symptoms rather than addressing the cause. In IBD, the overexpression of proinflammatory cytokines, such as tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, leads to a persistent intestinal inflammatory response that damages the intestinal mucosa. Recent advances in pharmacologic therapies that target specific cytokines, chemokines, and adhesion molecules have proved successful in alleviating symptoms for some patients. There are 2 selective adsorption apheresis devices that remove leukocytes from whole blood, which are currently available in Japan and Europe-the Cellsorba leukocytapheresis column and the Adacolumn adsorptive extracorporeal granulocyte/monocyte apheresis device. The purported mechanisms of action of these devices have been extensively reviewed and are believed to exert an immunomodulatory and/or anti-inflammatory effect on patients with systemic inflammatory disease. The clinical trials presented here indicate that selective leukocyte apheresis effectively removes activated granulocytes and monocytes/macrophages from peripheral blood while maintaining an excellent safety profile. Despite these findings, large controlled trials of selective leukocyte apheresis in the treatment of IBD are needed to determine the true efficacy of this approach.
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Emmrich J, Petermann S, Nowak D, Beutner I, Brock P, Klingel R, Mausfeld-Lafdhiya P, Liebe S, Ramlow W. Leukocytapheresis (LCAP) in the management of chronic active ulcerative colitis--results of a randomized pilot trial. Dig Dis Sci 2007; 52:2044-53. [PMID: 17410456 DOI: 10.1007/s10620-006-9696-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Accepted: 11/26/2006] [Indexed: 12/09/2022]
Abstract
Recent studies suggest that leukocytapheresis with Cellsorba is a valuable therapy for ulcerative colitis after failure of conventional treatment. In this study the potential of leukocytapheresis to induce remission in refractory chronic colitis under the conditions of European treatment guidelines was investigated. The therapeutic benefit of leukocytapheresis in the maintenance of remission was additionally elucidated. Twenty patients were treated weekly for 5 weeks. A significant decrease in the activity index was observed. Fourteen patients achieved clinical remission, and mucosal healing was observed endoscopically in six patients. After randomization these 14 patients in remission entered a second period of either monthly leukocytapheresis or no further treatment. In both groups steroids were tapered down. After 6 months, only one patient in the control group remained in remission, in contrast to five of eight patients in the leukocytapheresis group. In conclusion, leukocytapheresis may offer a therapeutic option in the induction and the maintenance of remission in chronic active ulcerative colitis.
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Affiliation(s)
- Jörg Emmrich
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany.
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Miyamoto H, Okahisa T, Iwaki H, Murata M, Ito S, Nitta Y, Akutagawa M, Kinouchi Y, Ohnishi Y, Oto J, Nishimura M. Influence of Leukocytapheresis Therapy for Ulcerative Colitis on Anemia and Hemodynamics. Ther Apher Dial 2007; 11:16-21. [PMID: 17309570 DOI: 10.1111/j.1744-9987.2007.00451.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In Japan, leukocytapheresis (LCAP) therapy has been carried out for ulcerative colitis as an effective therapy with a low incidence of side-effects. In the present study, we serially investigated the influence of LCAP therapy on anemia and hemodynamics in patients with ulcerative colitis using a non-invasive method with a Crit-Line monitor (CLM) (Hema Metrics Inc., Salt Lake City, UT and Boston, MA, USA). We carried out LCAP on 10 patients with ulcerative colitis using a CS-100 Cellsorba EX LCAP filter in 34 courses of LCAP. The mean hematocrit value, which was measured using the Crit-Line monitor, was 21.8 +/- 0.2% (21.0-22.4%), which showed no significant changes after each LCAP therapy. The actual erythrocyte count, hemoglobin and hematocrit values decreased by 244 000/mm3, 0.7 g/dL and 2.1%, respectively, however, the differences were insignificant. These values corresponded to 7.8, 8.0 and 7.6% of the values before LCAP, respectively. There were no significant changes in systolic blood pressure, diastolic blood pressure, or heart rate during LCAP. The results of this study suggest that one course of LCAP does not exacerbate anemia, and it does not influence hemodynamics. However, considering the exacerbation of anemia in patients with severe ulcerative colitis caused by massive melena, monitoring with a less invasive Crit-Line monitor and a vital information monitor might be useful.
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Affiliation(s)
- Hiroshi Miyamoto
- Department of Digestive and Cardiovascular Medicine, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan.
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Yamaji K, Onuma S, Yasuda M, Kanai Y, Tsuda H, Takasaki Y. Fluctuations in Peripheral Blood Leukocyte and Platelet Counts and Leukocyte Recruitment With Large Volume Leukocytapheresis in Healthy Volunteers. Ther Apher Dial 2006; 10:396-403. [PMID: 17096693 DOI: 10.1111/j.1744-9987.2006.00402.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ken Yamaji
- Department of Internal Medicine & Rheumatology, Juntendo University School of Medicine, Tokyo, Japan.
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Abstract
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%).
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Affiliation(s)
- William J Sandborn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Sawada K, Kusugami K, Suzuki Y, Bamba T, Munakata A, Hibi T, Shimoyama T. Leukocytapheresis in ulcerative colitis: results of a multicenter double-blind prospective case-control study with sham apheresis as placebo treatment. Am J Gastroenterol 2005; 100:1362-9. [PMID: 15929771 DOI: 10.1111/j.1572-0241.2005.41089.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Leukocytapheresis (LCAP) is a method of therapeutic apheresis that removes peripheral leukocytes. Previous studies showed that in patients with ulcerative colitis (UC), LCAP was more effective than high-dose steroid therapy, and it had few adverse effects. We investigated LCAP in a multicenter study using active and sham devices in a double-blind study in order to elucidate the placebo effect of extracorporeal treatment including anticoagulant medication. METHODS Twenty-five patients with active UC of severe or moderately severe grade were enrolled and assigned to the active group or the sham group. Six patients were excluded from the study and 19 (10 in the active group and nine in the sham group) were evaluated. LCAP (treatment using an active device or a sham device) was performed once a week for 5 wk, followed by two additional sessions during the next 4 wk at 2-wk intervals. Steroids and other medications were continued at the same dosage for 4 wk, which included a 2-wk pre-observation period and the first 2 wk after the start of the LCAP treatment. New medications or increase in the dosage of previous medication were prohibited until evaluation was conducted. RESULTS The clinical activity index (CAI) value of UC, indicated that the active group showed a significantly greater improvement (80%, 8/10) than the sham group (33%, 3/9; p<0.05). Adverse effects were observed in five patients (one in the active group and four in the sham group). None of these effects was severe and none of the sessions was terminated as a consequence of the adverse effects. CONCLUSION The results confirmed that LCAP is a safe and effective therapeutic option for patients with active UC.
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Affiliation(s)
- Koji Sawada
- Department of Gastroenterology, Hyogo College of Medicine, Nishinomiya, Japan
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Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Kikuyama M, Tanaka T, Kondo K, Tanaka K, Takai K. Decrease of reactive-oxygen-producing granulocytes and release of IL-10 into the peripheral blood following leukocytapheresis in patients with active ulcerative colitis. World J Gastroenterol 2005; 11:3085-90. [PMID: 15918195 PMCID: PMC4305845 DOI: 10.3748/wjg.v11.i20.3085] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical efficacy of leukocytapheresis (LCAP) in patients with active ulcerative colitis (UC), and to elucidate the mechanisms by determining the changes in the cytokine levels in the peripheral blood and of the functions of the peripheral blood leukocytes in these patients.
METHODS: The subjects were 19 patients with active UC, with a mean clinical activity index (CAI) of 9.2. The LCAP was conducted using Cellsorba E. In each session of LCAP, 2-3 L of blood at the flow rate of 30-50 mL/min was processed. The treatment was carried out in approximately 1-h sessions, once a week, for 5-10 wk. Blood samples for determination of the cytokine levels were collected from the inflow side of the column (site of dehematization; at the start of LCAP) and outflow side of the column (at the end of LCAP). Blood samples for the determination of reactive-oxygen-producing cells were collected from the peripheral blood before and after LCAP.
RESULTS: LCAP resulted in clinical improvement in all the 19 patients of UC recruited for this study. Remission (CAI: ≤4) was noted in 15 (79%) of the 19 patients. The blood level of the pro-inflammatory cytokine IL-6 was found to be decreased following treatment by LCAP, and the level of the anti-inflammatory cytokine IL-10 at the outflow side of the LCAP column was found to be significantly elevated as compared to that at the inflow side of the column. The reactive-oxygen-producing granulocytes in the peripheral blood of UC patients was increased as compared to that in healthy persons and the increase was found to be decreased following treatment by LCAP.
CONCLUSION: LCAP exerted a high therapeutic efficacy in patients with active UC. Our findings suggest that LCAP is associated with enhanced production of the inhibitory cytokine IL-10 to indirectly inhibit the functions of the inflammatory leukocytes, and that inflammation is also considerably attenuated by the direct removal of reactive-oxygen-producing neutrophils from the peripheral blood.
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Affiliation(s)
- Hiroyuki Hanai
- Department of Endoscopic and Photodynamic Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan.
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20
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Sawada K, Egashira A, Ohnishi K, Fukunaga K, Kusaka T, Shimoyama T. Leukocytapheresis (LCAP) for management of fulminant ulcerative colitis with toxic megacolon. Dig Dis Sci 2005; 50:767-73. [PMID: 15844716 DOI: 10.1007/s10620-005-2571-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Leukocytapheresis (LCAP) is a method of therapeutic apheresis to remove patients' peripheral leukocytes by extracorporeal circulation. Previous studies showed that LCAP for the treatment of ulcerative colitis (UC) was more effective and had fewer adverse effects compared to high-dose steroid therapy. However, there are no reports on the application of LCAP for UC patients with toxic megacolon (TM). This study reports the effectiveness and safety of LCAP in treating patients with severe or fulminant UC with TM. Six patients were enrolled in this study and LCAP sessions were performed three times per week for 2 weeks, followed by four further times in the next 4 weeks. After completion of therapy, four patients improved in TM and went into the remission stage of UC. The average Rachmilewitz clinical activity index of these four patients improved from 19.5 to 1. The remaining two patients had to undergo colectomy, however, the symptoms had been mitigated by LCAP and the operations were completed without any problems. These results suggest that LCAP is an additional effective and safe option for TM management in preventing colectomy or for bridging to a safer operation.
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Affiliation(s)
- Koji Sawada
- Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan.
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21
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Nagase K, Fukunaga K, Ohnishi K, Kusaka T, Matoba Y, Sawada K. Detection of specific IgE antibodies to nafamostat mesilate as an indication of possible adverse effects of leukocytapheresis using nafamostat mesilate as anticoagulant. Ther Apher Dial 2004; 8:45-51. [PMID: 15128019 DOI: 10.1111/j.1526-0968.2004.00086.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim was to determine whether adverse effects of leukocytapheresis (LCAP) are related to nafamostat mesilate (NM) as an anticoagulant. Anti-NM IgE were detected in inflammatory bowel disease (IBD) patients who were administrated LCAP in our institute. Forty-nine patients (ulcerative colitis (UC)/Crohn's disease (CD): 30/19) were evaluated. Anti-NM IgE was measured by the ELISA method. Total IgE level and eosinophil count was tested concurrently. We retrospectively checked the presence of allergic symptoms and medications used concurrently with LCAP. Anti-NM IgE were present in six symptomatic patients (6/49; 12.2%) whose adverse effects were highly suspected to be from NM. However, 21 patients showed anti NM IgE-negative, in spite of the fact that their adverse effects were also highly suspected to be from NM. Through the detection of anti-NM IgE alone we could not estimate the relevance of NM as an anticoagulant to the adverse effects of LCAP.
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Affiliation(s)
- Kazuko Nagase
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
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22
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Mizushima T, Ito T, Kishi D, Kai Y, Tamagawa H, Nezu R, Kiyono H, Matsuda H. Therapeutic effects of a new lymphocyte homing reagent FTY720 in interleukin-10 gene-deficient mice with colitis. Inflamm Bowel Dis 2004; 10:182-92. [PMID: 15290910 DOI: 10.1097/00054725-200405000-00002] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND FTY720 is a novel reagent that possesses potent immunosuppressive activity. The immunosuppression induced by FTY720 is mediated by completely different mechanisms from those of conventional immunosuppressants, that is, by altering the tissue distribution of lymphocytes rather than inhibiting activation. In this study, we examined the efficacy of FTY720 in the treatment of chronic colitis in an interleukin-10 gene-deficient (IL-0-/-) mouse model. METHODS FTY720 was administered orally for 4 weeks to IL-10-/- mice with clinical signs of colitis. The gross and histologic appearance of the colon and the numbers, phenotype, cytokine production, and apoptosis of lymphocytes were compared with those characteristics in a control group. RESULTS Single-dose administration of FTY720 resulted in the sequestration of circulating lymphocytes within the secondary lymphoid tissues. Four-week administration resulted in a significant reduction of the CD4+ T lymphocytes subpopulation in the colonic lamina propria and IFN-gamma production of the colonic lymphocytes, accompanied by a significant decrease in the severity of colitis. CONCLUSIONS Treatment of established colitis in IL-10-/- mice with FTY720 ameliorated the colitis, probably as a result of decreasing the number of lymphocytes in the colonic mucosa and an associated reduction in IFN-gamma production.
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Affiliation(s)
- Tsunekazu Mizushima
- Department of Surgery (E1), Osaka University Graduate School of Medicine, Japan
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23
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Yamaji K, Yang K, Tsuda H, Hashimoto H. Fluctuations in the peripheral blood leukocyte and platelet counts in leukocytapheresis in healthy volunteers. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:402-12. [PMID: 12460402 DOI: 10.1046/j.1526-0968.2002.00459.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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Ortolano GA, Capetandes A, Wenz B. A review of leukofiltration therapy for decreasing the morbidity associated with cardiopulmonary bypass and acute inflammatory bowel disease. Ther Apher Dial 2002; 6:119-29. [PMID: 11982952 DOI: 10.1046/j.1526-0968.2002.00338.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Complications of cardiopulmonary bypass (CPB) and acute inflammatory bowel disease (IBD) are associated with increased morbidity and cost. During reperfusion post-CPB, activated neutrophils adhere to microvascular endothelial cells mediated by cell adhesion molecules (CAMs) and cytokines/chemokines with subsequent myocardial damage caused by activated neutrophil-derived oxidants and enzymes. Leukofiltration was shown to reduce myocardial reperfusion injury and improve gas exchange as suggested by improvements in surrogate markers of inflammation and clinical end points. In acute IBD, characterized by rectal bleeding and protracted hospital stays, circulating neutrophils emigrate to the inflamed colon and adhere to microvascular endothelial cells by CAMs. Multiple treatments with leukofiltration in IBD were shown to induce long-term remission of acute IBD. Hence, leukofiltration may reduce reperfusion injury and rectal bleeding in CPB and IBD, respectively, and therefore decrease the morbidity and cost associated with these diseases.
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Affiliation(s)
- Girolamo A Ortolano
- Pall Medical Scientific and Laboratory Services, Pall Corporation, Port Washington, New York 11050, USA
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25
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Fukunaga K, Sawada K, Fukuda Y, Matoba Y, Onishi K, Fukui S, Yamamura M, Satomi M, Shimoyama T. A case report: first case of filtration leukocytapheresis for a patient of aortitis syndrome associated with ulcerative colitis. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:93-8. [PMID: 11886584 DOI: 10.1046/j.1526-0968.2002.00317.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
An 18-year-old woman was treated with leukocytapheresis (LCAP) for her combined ulcerative colitis (UC) and aortitis syndrome (AS). Because a close relationship between these two diseases has been suspected based on their etiological and/or pathological findings, we had hypothesized that LCAP, which has satisfactory effects on inflammatory bowel disease such as UC and Crohn's disease might be effective for both her UC and her AS. After informed consent, LCAP therapy was performed once a week for a total of 7 times. Endoscopic remission of the UC was observed. Even though there were no significant improvements in her subjective symptoms of AS such as side-neck pain and dizziness, objective evidence of improvement was obtained when the patient's condition was compared before and after LCAP by angiography, angio-magnetic resonance imaging, and the plethysmogram of her fingertips. These results suggest that LCAP may be valuable as a new adjunct therapy for AS.
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Affiliation(s)
- Ken Fukunaga
- Division of Gastroenterology, Hyogo College of Medicine, Hyogo, Japan.
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