Successful long-term (22 year) treatment of limited scleroderma using therapeutic plasma exchange: Is blood rheology the key?

Evaluating the safety and efficacy of plasma therapy/plasmapheresis for systemic sclerosis - A comprehensive systematic review

INTRODUCTION

Systemic sclerosis (SSc) is an autoimmune disorder with fibrosis in multiple organs, autoantibodies, and microvascular abnormalities. Its origin is unclear, but it may result from circulatory damage, collagen metabolism disruption, and modifications in immunoregulation. The disease affects various organs and has high morbidity and mortality rates. SSc-related complications are managed using immunosuppressive medications that target autoantibodies. The main objective of this study was to assess the safety and efficacy of plasma therapy/plasmapheresis in managing SSc.

METHODS

This systematic review followed PRISMA and IMRAD guidelines, using PICO framework for study selection based on MeSH terms and Boolean operators. It included cross-sectional, randomized control trials, and clinical studies on plasma therapy for SSc. Standardized protocols were used for data extraction and risk of bias assessment.

DISCUSSION

Plasma therapy is a growing treatment option for managing SSc with reported benefits, especially in early stages and specific organ complications. However, further investigation and standardized protocols are needed. This review explores the potential of plasma therapy in improving the quality of life for SSc patients and in combination with other treatments.

RESULT

The review analyzed 15 articles, including research papers, controlled trials, and case reports. Plasma therapy, involving Plasmapheresis and therapeutic plasma exchange (TPE), improved symptoms of SSc like Raynaud phenomenon, vasculitis, muscle dysfunction, and digital ulcers. However, outcomes varied among studies, and some advanced cases showed limited benefits.

CONCLUSION

Plasma therapy can be an effective way of managing the symptoms of systemic sclerosis with low incidence of adverse events. However, the exact mechanism behind this treatment is still unclear. Therefore, additional studies are required.

Rheopheresis for Digital Ulcers and Raynaud's Phenomenon in Systemic Sclerosis Refractory to Conventional Treatments

Raynaud's phenomenon (RP) is almost universally present in patients with Systemic Sclerosis (SSc). RP represents a generalized vasculopathy and potentially lead to digital ulcers (DU), which may be complicated by superinfection, tissue necrosis, and limb loss. We report the analysis of an extracorporeal procedure in a 36-year-old female patient with diffuse SSc with refractory RP and DU despite treatment with diltiazem, candesartan, sildenafil, and intravenous iloprost. We performed rheopheresis (RheoP), a variant of double-filtration plasmapheresis, as a potential new treatment option for refractory patients despite optimal medical therapy. We performed two RheoP per week every 4 weeks for a total of 3 months. Clinical improvement in DU healing occurred with no adverse events directly related to the treatment. While there was no reduction in the number of Raynaud attacks with RheoP, a significant reduction of the duration of attacks from a median of 15 (5-45, 95% CI 10-15) to 7 (3-30, 95% CI 6-10) minutes with an improvement of the Raynaud Condition Score (RCS) improved from 4 to 2. In conclusion, RheoP is a feasible and potentially beneficial treatment modality in patients with refractory RP and DU. We propose that RheoP should be investigated in a larger number of patients in a clinical trial setting.

The role of plasma exchange in the management of autoimmune disorders

Therapeutic plasma exchange (TPE) has been mainly used in the treatment of autoimmune diseases. The main mechanisms of action of TPE include the removal of circulating autoantibodies, immune complexes, complement components, cytokines and adhesion molecules, along with sensitization of antibody-producing cells to immunosuppressant agents. TPE is useful in autoimmune haematological, renal, rheumatic and neurological diseases, and is recommended for acute disorders, together with relapsed or worsened chronic diseases that are often unresponsive to conventional treatments. The American Society for Apheresis and the British Society of Haematology have published guidelines on the clinical use of apheresis procedures, indicating the different levels of efficacy of TPE. Based on the evidence from current literature and our personal experience, this review discusses the indications and the suggested regimens for TPE in autoimmune haematological and non-haematological disorders.

Therapeutic plasma exchange for the treatment of systemic sclerosis: A comprehensive review and analysis

Background

Therapeutic plasma exchange has been tried as a treatment approach for systemic sclerosis since 1978 based on the rationale that some circulating factor is involved in disease pathogenesis, for example, autoantibodies or immune complexes, and that removing the potential pathogenic factors could lead to symptom improvement. Based on our impression that clinicians and researchers are largely unaware that a large volume of research has been published about the use of therapeutic plasma exchange as a treatment for systemic sclerosis, we conducted a comprehensive review and analysis of all published research on this topic.

Results

We identified 46 relevant articles that met our search criteria, involving a total of 572 patients. Of these, 19 were case studies; the rest ranged from small observational studies to prospective randomized clinical trials. In all but two studies, most patients receiving therapeutic plasma exchange showed improvements in both clinical symptoms and laboratory markers, including significant improvement in Raynaud's symptoms and healing of digital ulceration after three to four weekly treatments. The beneficial effects from even a short course of therapeutic plasma exchange treatments were long-lasting, typically 6 months or longer. Therapeutic plasma exchange was very well tolerated. Adverse events were rare and, in almost all cases, mild and transitory.

Conclusion

These results suggest that long-term therapeutic plasma exchange may offer a low-risk way to control and in some cases reverse systemic sclerosis symptoms. The mechanism for the clinical improvements seen from therapeutic plasma exchange in systemic sclerosis patients is unclear. Therefore, additional studies of therapeutic plasma exchange effects in systemic sclerosis appear to be highly desirable.