Experience with protein A-immunoadsorption in treatment-resistant adult immune thrombocytopenic purpura

Abstract

Extracorporeal immunoadsorption of plasma to remove IgG and circulating immune complexes (CIC) was evaluated as a therapy for adults with treatment-resistant immune thrombocytopenic purpura (ITP). Seventy-two patients with initial platelet counts less than 50,000/microL who had failed at least two other therapies were studied. They received an average of six treatments of 0.25 to 2.0 L plasma per procedure over a 2- to 3-week period using columns of staphylococcal protein A-silica (PROSORBA immunoadsorption treatment columns; IMRE Corp, Seattle, WA). The treatments caused an acute increase in the platelet count to greater than 100,000/microL in 18 patients and to 50,000 to 100,000/microL in 15 patients. The median time to response was 2 weeks. Responses were transient (less than 1 month duration) in seven of those patients (10%), but no additional relapses were reported over a follow- up period of up to 26 months (mean of 8 months). Clinical responses were associated with significant decreases in specific serum platelet autoantibodies (including anti-glycoprotein IIb/IIIa), platelet- associated Ig, and CIC. Thirty percent of treatments were associated with transient mild to moderate side effects usually presenting as a hypersensitivity-type reaction. Continued administration of failed therapies for ITP, which always included low-dose corticosteroids (less than or equal to 30 mg/d), had no demonstrable influence on the effectiveness of immunoadsorption treatment but did depress the incidence and severity of side effects. The degree of effectiveness of protein A immunoadsorption therapy in patients with treatment-resistant ITP is promising and further controlled studies in this patient population are warranted.

Immunoadsorption with tryptophan columns: A therapeutic option for the treatment of rheumatoid arthritis with septic complications

“…Immunoadsorption has been used in the treatment of many autoimmune diseases, which remain unresponsive to other therapies. Idiopathic thrombocytopenic purpura, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and myasthenia gravis are examples of autoimmune disorders with good response on treatment with extracorporeal therapy [5][6][7][8]. The bridging of infectious complications described here has similarities with using immunoadsorption for infectious complications in severe pemphigus, which has been also successfully done with tryptophan immunoadsortion [9].…”

Management of hematological disorders and cancer

“…Of 36 HIV positive patients treated off-line, 16 showed an increase of SO% or more in platelet count [ 131. In a recent study of non-HIV ITP, 26 of 72 patients had increases in platelet count to >SO,OOO/pl that persisted for over two months [14]. The mechanism of action of this therapy is not clear.…”

“…In the past five years, there have been a number of reports of treatment of PTP with IVIG [12][13][14]. Most of these have also described fairly prompt resolution of thrombocytopenia.…”

“…Although likely to be effective, such treatment may be TPEX could be used for this purpose [ 131. More recently, an immunoadsorption process for IgG has been adapted for this situation [14,15]. Plasma from an apheresis device flows through one of a pair of columns containing staphylococcal protein A bound to sepharose; plasma emerging from the column is depleted of IgG (except IgG3).…”

“…However, the role of photopheresis for patients with more extensive skin lesions (plaque and tumor stages) and/or systemic involvement is controversial, and these patients might better be managed with topical UVA, cytotoxic agents, electron-beam therapy or more intense chemotherapy. Photopheresis is also under investigation as a potentially beneficial immunomodulatory procedure in progressive systemic sclerosis [ 121, other autoimmune diseases [ 131, cardiac allograft rejection [ 14,151, and graft-versus-host disease [ 12,141.…”