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Queiroz ALGD, Soares Neto HR, Kobayashi TT, Silva SMCDA. Plasma exchange in inflammatory demyelinating disorders of the central nervous system: reasonable use in the clinical practice. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:296-307. [PMID: 37059439 PMCID: PMC10104758 DOI: 10.1055/s-0042-1758447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Plasma exchange (PLEX) is a therapeutic apheresis modality in which the plasma is separated from inflammatory factors such as circulating autoreactive immunoglobulins, the complement system, and cytokines, and its therapeutic effect is based on the removal of these mediators of pathological processes. Plasma exchange is well established for various neurological disorders, and it is applied successfully in central nervous system inflammatory demyelinating diseases (CNS-IDD). It mainly modulates the humoral immune system; thus, it has a greater theoretical effect in diseases with prominent humoral mechanisms, such as neuromyelitis optica (NMO). However, it also has a proven therapeutic effect in multiple sclerosis (MS) attacks. Several studies have suggested that patients with severe attacks of CNS-IDD have poor response to steroid therapy but show clinical improvement after the PLEX treatment. Currently, PLEX is generally established only as a rescue therapy for steroid unresponsive relapses. However, there are still research gaps in the literature regarding plasma volume, number of sessions, and how early the apheresis treatment needs to started. Thus, in the present article, we summarize the clinical studies and meta-analyses, especially about MS and NMO, outlining clinical data regarding the experience with therapeutic PLEX in severe attacks of CNS-IDD, the clinical improvement rates, the prognostic factors of a favorable response, and highlighting the likely role of the early apheresis treatment. Further, we have gathered this evidence and suggested a protocol for the treatment of CNS-IDD with PLEX in the routine clinical practice.
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Affiliation(s)
| | | | - Thiago Taya Kobayashi
- Hospital do Servidor Público Estadual de São Paulo, Serviço de Neurologia, São Paulo SP, Brazil
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Pfeuffer S, Rolfes L, Wirth T, Steffen F, Pawlitzki M, Schulte-Mecklenbeck A, Gross CC, Brand M, Bittner S, Ruck T, Klotz L, Wiendl H, Meuth SG. Immunoadsorption versus double-dose methylprednisolone in refractory multiple sclerosis relapses. J Neuroinflammation 2022; 19:220. [PMID: 36071461 PMCID: PMC9450381 DOI: 10.1186/s12974-022-02583-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Objective Intravenous methylprednisolone is the standard treatment for a multiple sclerosis relapse; however, this fails to improve symptoms in up to one quarter of patients. Immunoadsorption is an accepted treatment for refractory relapses, but prospective comparator-controlled studies are missing. Methods In this observational study, patients with steroid-refractory acute multiple sclerosis relapses receiving either six courses of tryptophan-immunoadsorption or double-dose methylprednisolone therapy were analysed. Outcomes were evaluated at discharge and three months later. Immune profiling of blood lymphocytes and proteomic analysis were performed by multi-parameter flow cytometry and Olink analysis, respectively (NCT04450030). Results 42 patients were enrolled (methylprednisolone: 26 patients; immunoadsorption: 16 patients). For determination of the primary outcome, treatment response was stratified according to relative function system score changes (“full/best” vs. “average” vs. “worse/none”). Upon discharge, the adjusted odds ratio for any treatment response (“full/best” + ”average” vs. “worse/none”) was 10.697 favouring immunoadsorption (p = 0.005 compared to methylprednisolone). At follow-up, the adjusted odds ratio for the best treatment response (“full/best” vs. “average” + ”worse/none”) was 103.236 favouring IA patients (p = 0.001 compared to methylprednisolone). Similar results were observed regarding evoked potentials and quality of life outcomes, as well as serum neurofilament light-chain levels. Flow cytometry revealed a profound reduction of B cell subsets following immunoadsorption, which was closely correlated to clinical outcomes, whereas methylprednisolone had a minimal effect on B cell populations. Immunoadsorption treatment skewed the blood cytokine network, reduced levels of B cell-related cytokines and reduced immunoglobulin levels as well as levels of certain coagulation factors. Interpretation Immunoadsorption demonstrated favourable outcomes compared to double-dose methylprednisolone. Outcome differences were significant at discharge and follow-up. Further analyses identified modulation of B cell function as a potential mechanism of action for immunoadsorption, as reduction of B cell subsets correlated with clinical improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02583-y.
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Affiliation(s)
- Steffen Pfeuffer
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Leoni Rolfes
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Timo Wirth
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Falk Steffen
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Marc Pawlitzki
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Catharina C Gross
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Marcus Brand
- Medical Department D - Nephrology, University Hospital Muenster, Muenster, Germany
| | - Stefan Bittner
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Tobias Ruck
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Luisa Klotz
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Sven G Meuth
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany. .,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany.
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Zhang J, Fan A, Wei L, Wei S, Xie L, Li M, Zhang W, Liu Q, Yang K. Efficacy and safety of plasma exchange or immunoadsorption for the treatment of option neuritis in demyelinating diseases: A systematic review and meta-analysis. Eur J Ophthalmol 2021; 32:1857-1871. [PMID: 34918576 DOI: 10.1177/11206721211065218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are no systematic reviews yet that evaluated the effects of PE/IA in patients with optic neuritis (ON) in demyelinating diseases. A meta-analysis of available study is needed to further explore the value of plasma exchange (PE) or immunoadsorption (IA) in treating ON in demyelinating diseases. METHODS All relevant articles published on PubMed, Web of Science, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), VIP Database, Wanfang, Sinomed and ophthalmology professional websites were searched. Study characteristics, demographic characteristics, clinical features and outcome measures were extracted. Response rate, adverse events (AE) rate, serious adverse event (SAE) rate, the log of the minimum angle of resolution (logMAR), visual outcome scale (VOS) and expanded disability status scales (EDSS) were evaluated using a random-effects model. RESULTS 35 studies were included between 1985 and 2020, containing 1191 patients. The response rates of PE and IA in acute attack of ON were 68% and 82% respectively. LogMAR (-0.60 to - 1.42) and VOS (-1.10 to -1.82) had been significantly improved from within 1 month to more than 1 month after PE treatment. Besides, we found that logMAR improved 1.78, 0.95 and 0.38, respectively ,when the time from symptom onset to the first PE/IA was less than 21 days, 21-28 days, and more than 28 days. The pooled mean difference of EDSS was -1.14.Adverse effects rate in patients with PE or IA were 0.20 and 0.06, respectively. CONCLUSION The meta-analysis provided evidence that PE/IA treatment was an effective and safe intervention, and it is recommended that early initiation of PE/IA treatment is critical.
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Affiliation(s)
- Jianping Zhang
- Department of Ophthalmology, 74713Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Aifang Fan
- Department of Ophthalmology, 91589Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Lili Wei
- Evidence Based Medicine Center, School of Basic Medical Sciences, 12426Lanzhou University, Lanzhou, Gansu, China
| | - Shihui Wei
- Department of Ophthalmology, 104607The Chinese People's Liberation Army General Hospital, Beijing, China
| | - Lindan Xie
- Department of Ophthalmology, 104607The Chinese People's Liberation Army General Hospital, Beijing, China
| | - Meixuan Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, 12426Lanzhou University, Lanzhou, Gansu, China
| | - Wenfang Zhang
- Department of Ophthalmology, 74713Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Qin Liu
- Department of Ophthalmology, 91589Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, 12426Lanzhou University, Lanzhou, Gansu, China
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Therapeutic plasma exchange in MS refractory relapses: Long-term outcome. Mult Scler Relat Disord 2021; 55:103168. [PMID: 34332460 DOI: 10.1016/j.msard.2021.103168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 07/22/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Therapeutic plasma exchange (TPE) is considered a treatment option for steroid-refractory multiple sclerosis (MS) relapses. Our objective was to assess long-term clinical response to TPE in MS steroid-refractory exacerbations. METHODS Retrospective study of relapsing remitting MS (RRMS) patients presenting intravenous methylprednisolone (IVMPS)-refractory relapses, who underwent TPE. Response to TPE was assessed at 1, 3, 6, 12 and 24-months post-treatment, and compared to a second group of RRMS patients with similar demographic and clinical characteristics presenting, IVMPS-refractory relapses but not treated with TPE. Multivariate regression analysis was used to assess potential predictors of significant clinical response. RESULTS Between 2011 to 2020, a total of 23 RRMS patients were treated with TPE. Twenty-one patients not receiving the treatment served as controls. No differences in demographic or clinical characteristics, or predictors of clinical improvement after TPE were detected between groups. Seventy-eight percent of patients treated with TPE presented clinical improvement at 24 months. TPE-treated patients presented lower EDSS scores at 6 and at 24 months. Younger age, presence of gadolinium-enhancing lesions and TPE treatment were associated with better clinical outcomes. No life-threatening side effects were reported. CONCLUSIONS TPE is a safe and well tolerated procedure that decreases long-term disability in RRMS patients with IVMPS-refractory relapses.
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Li H, Lian G, Wang G, Yin Q, Su Z. A review of possible therapies for multiple sclerosis. Mol Cell Biochem 2021; 476:3261-3270. [PMID: 33886059 DOI: 10.1007/s11010-021-04119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 02/23/2021] [Indexed: 01/22/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune chronic inflammatory disease of the central nervous system with a wide range of symptoms, like executive function defect, cognitive dysfunction, blurred vision, decreased sensation, spasticity, fatigue, and other symptoms. This neurological disease is characterized by the destruction of the blood-brain barrier, loss of myelin, and damage to neurons. It is the result of immune cells crossing the blood-brain barrier into the central nervous system and attacking self-antigens. Heretofore, many treatments proved that they can retard the progression of the disease even though there is no cure. Therefore, treatments aimed at improving patients' quality of life and reducing adverse drug reactions and costs are essential. In this review, the treatment approaches to alleviate the progress of MS include the following: pharmacotherapy, antibody therapy, cell therapy, gene therapy, and surgery. The current treatment methods of MS are described in terms of the prevention of myelin shedding, the promotion of myelin regeneration, and the protection of neurons.
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Affiliation(s)
- Hui Li
- Hengyang Medical School, University of South China, Hengyang City, 421001, Hunan Province, China
| | - Gaojian Lian
- Hengyang Medical School, University of South China, Hengyang City, 421001, Hunan Province, China
| | - Guang Wang
- Hengyang Medical School, University of South China, Hengyang City, 421001, Hunan Province, China
| | - Qianmei Yin
- Hengyang Medical School, University of South China, Hengyang City, 421001, Hunan Province, China
| | - Zehong Su
- Hengyang Medical School, University of South China, Hengyang City, 421001, Hunan Province, China.
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Dorst J. Apheresis in Neurological Disorders. J Clin Med 2020; 9:jcm9103211. [PMID: 33036156 PMCID: PMC7600998 DOI: 10.3390/jcm9103211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Johannes Dorst
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
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Dorst J, Fillies F, Dreyhaupt J, Senel M, Tumani H. Safety and Tolerability of Plasma Exchange and Immunoadsorption in Neuroinflammatory Diseases. J Clin Med 2020; 9:jcm9092874. [PMID: 32899499 PMCID: PMC7565027 DOI: 10.3390/jcm9092874] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022] Open
Abstract
Plasma exchange (PE) and immunoadsorption (IA) are frequently used for treatment of various autoimmune-mediated neurological diseases, including multiple sclerosis (MS), chronic inflammatory demyelinating polyneuropathy (CIDP), and Guillain-Barré syndrome (GBS). Although both methods are generally regarded as well-tolerated treatment options, evidence for safety and tolerability is low for most indications and largely relies on small case series. In this study, we retrospectively analysed adverse events (AEs) and laboratory changes in 284 patients with various neurological indications who received either PE (n = 65, 113 cycles) or IA (n = 219, 435 cycles) between 2013 and 2020 in our Neurology department. One standard treatment cycle for PE as well as IA consisted of five treatments on five consecutive days. During every treatment, the 2.0-2.5-fold individual plasma volume (PV) was treated in IA, while in PE, the 0.7-fold individual PV was replaced by human albumin solution. Overall, both methods showed an excellent safety profile; no deaths of life-threatening adverse events were recorded. Severe AEs (corresponding to grade 3 on the Common Terminology Criteria for Adverse Events grading scale v5.0) including three patients with sepsis, one pneumonia, and one pneumothorax were present in 5/435 IA cycles (1.1%); in the PE group, no severe AEs were recorded. Furthermore, although advantageous tolerability is generally considered the main advantage of IA over PE, we found that overall frequency of AEs (including grades 1 and 2) was higher in IA (67.1% of all cycles) compared to PE (35.4%; p < 0.001). The low incidence of AEs in PE might be caused by the lower PV exchanged during each treatment (0.7-fold) compared to previous studies which predominantly exchanged the 1.0-1.5-fold PV. In order to verify this hypothesis as well as confirming the efficacy of this lower-dosed scheme, prospective studies comparing different treatment regimens are needed.
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Affiliation(s)
- Johannes Dorst
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (F.F.); (M.S.); (H.T.)
- Correspondence:
| | - Frank Fillies
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (F.F.); (M.S.); (H.T.)
| | - Jens Dreyhaupt
- Institute for Epidemiology and Medical Biometry, University of Ulm, 89081 Ulm, Germany;
| | - Makbule Senel
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (F.F.); (M.S.); (H.T.)
| | - Hayrettin Tumani
- Department of Neurology, University of Ulm, 89081 Ulm, Germany; (F.F.); (M.S.); (H.T.)
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Marrodan M, Gaitán MI, Correale J. Spinal Cord Involvement in MS and Other Demyelinating Diseases. Biomedicines 2020; 8:E130. [PMID: 32455910 PMCID: PMC7277673 DOI: 10.3390/biomedicines8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Diagnostic accuracy is poor in demyelinating myelopathies, and therefore a challenge for neurologists in daily practice, mainly because of the multiple underlying pathophysiologic mechanisms involved in each subtype. A systematic diagnostic approach combining data from the clinical setting and presentation with magnetic resonance imaging (MRI) lesion patterns, cerebrospinal fluid (CSF) findings, and autoantibody markers can help to better distinguish between subtypes. In this review, we describe spinal cord involvement, and summarize clinical findings, MRI and diagnostic characteristics, as well as treatment options and prognostic implications in different demyelinating disorders including: multiple sclerosis (MS), neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and glial fibrillary acidic protein IgG-associated disease. Thorough understanding of individual case etiology is crucial, not only to provide valuable prognostic information on whether the disorder is likely to relapse, but also to make therapeutic decision-making easier and reduce treatment failures which may lead to new relapses and long-term disability. Identifying patients with monophasic disease who may only require acute management, symptomatic treatment, and subsequent rehabilitation, rather than immunosuppression, is also important.
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Affiliation(s)
| | | | - Jorge Correale
- Neurology Department, Fleni, C1428AQK Buenos Aires, Argentina; (M.M.); (M.I.G.)
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