Immunoadsorption Therapy in Patients With Multiple Sclerosis With Steroid-Refractory Optical Neuritis

Michael J Koziolek; Desiree Tampe; Matthias Bühr; Hassan Dihazi; Klaus Jung; Dirk Fitzner; Reinhard Klinge; Gerhard A Müller; Bernd Kitze

Disclosures

J Neuroinflammation. 2012;9(80) 

In This Article

Results

IA treatments were started after a mean time of 26.6 days after the initial symptoms and 10.8 days after the start of corticosteroid therapy. Each patient received at least two courses of corticosteroid therapy prior to IA therapy, with a mean cumulative dose of 10.9 g prednisolone equivalent but without a significant improvement, thus fulfilling the indication of therapeutic apheresis as adjunct treatment. An improvement of visual acuity up to 0.6 or more was achieved in eight of eleven patients (72.7%) undergoing IA treatment (responder group). Two patients did not respond to therapy at any time point and one patient improved during IA therapy but deteriorated shortly after the end of IA therapy, associated with the incidence of a jugular venous thrombosis on the same side (non-responder group). The relevant data of patients' characteristics are shown in Table 1.

Visual Acuity

Mean visual acuity of all patients significantly improved with a baseline value of 0.12 ± 0.12 before the start of IA, 0.36 ± 0.33 (P = 0.0234) after the third IA and 0.72 ± 0.38 (day 180 ± 10 after IA; P < 0.001). The effect was even more pronounced in the responder group. Mean visual acuity before start of IA was 0.15 ± 0.12 with an increase after the third IA to 0.47 ± 0.32 (P = 0.0252 Bonf. n.s.) and even more up to 0.89 ± 0.15 (P < 0.0001 Bonf. sig.) at day 180 ± 10 after IA. By contrast, in the non-responder group, no significant changes of visual acuity were detectable. Results are summarized in Figure 1.

Figure 1.

Time-course of visual acuities of the affected eyes assessed by standard charts in 11 patients with multiple sclerosis treated by immunoadsorption. Visual acuities were shown as box plots (outliers marked as X) at baseline (visit 0), after three IA therapies (visit 3), after five IA therapies (visit 5), after 30 days (visit 6), after 60 days (visit 7), and after 180 days (visit 8). Three patients did not show long-term improvement of visual acuity, they were termed non-responders in this study (shown as filled circles, partially overlapping each other). AE: affected eyes; sign.: significant (pairwise comparison to baseline).

Relief of visual impairment inversely correlated with the time interval between the start of symptoms and the beginning of IA therapy (r = -0.539) with a trend (P = 0.08) favoring positive clinical response in early opposed to late IA initiation.

Visual Evoked Potentials

Before IA treatment, visual evoked potentials could not be identified in six of our patients with MS due to the severity of the optical neuritis. However, after treatment in four of these participants, potentials recovered at day 60. In five patients, the visual evoked potential amplitudes as well as latencies before and after IA could be compared. The mean amplitude was 2.31 ± 2.57 mV at baseline, 3.34 ± 2.60 mV after the last IA, and 5.69 ± 1.76 mV at day 60 (P = 0.37). Latencies did not show recovery in those five patients from baseline (107.6 ± 21.7 ms) until day 60 ± 10 (112.3 ± 17.1 ms).

Expanded Disability Status Scale and Incapacity Status Scale

The EDSS continuously improved in the responder group starting from 4.06 ± 1.82 at baseline to 3.44 ± 2.38 after the last IA to a minimum of 2.81 ± 2.72 at day 60 ± 10 (P = 0.58), in contrast to the non-responder group who showed no changes. However, EDSS is clearly dominated by ambulation[12] and rather insensitive for visual dysfunction.[13] In parallel, ISS ameliorated in the responder group from 8.00 ± 9.02 at baseline with a continuous decrease to a minimum of 5.75 ± 6.78 at day 180 ± 10 (P = 0.04), in contrast to no significant changes in the non-responder group.

Side Effects

In total, 55 IA treatments were analyzed. Mild side effects were often reported and caused slight discomfort to the patients, such as coldness, cough, dizziness, headache, temporary hypertension, lacrimation, muscular cramps, nausea, palpations, pruritus, paresthesia, rhinorrhea, sweating, tinnitus or vomiting. They were transient and could be easily managed without therapy.

Ten moderate side effects were recorded during the IA phase. These included vascular access problems such as central venous catheter infection and jugular venous thrombosis as well as therapy-associated events that included chest pain, dyspnoe, transient hypotension and urticaria, which could be easily managed by approved medical interventions. Two patients developed febrile infections (common cold and phlebitis of a peripheral vein) within 24 h of IA, which were possibly related to short-term immune dysfunction caused by corticosteroid therapy and IA. No severe side effects occurred. Results are summarized in Table 2.

Laboratory Data

In routine analyses, no significant changes were seen for the following values: partial thromboplastin time, hemoglobin, hematocrit, thrombocytes, sodium, calcium, creatinine, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, creatine kinase and C-reactive protein. Significant changes were detected for fibrinogen, leukocytes and total protein. Increased leukocyte counts at baseline were likely caused by corticosteroid therapy before starting IA.

Immunoglobulins IgA, IgG and IgM as well as complement components C3c and C4 significantly decreased during IA therapy (P < 0.01). After the end of IA, however, these parameters gradually recovered and increased beyond baseline values (as shown for IgG and C3c in Figure 2A, B). We found a significant decrease of sIL-2R at a rate of -35.4 ± 20.7% (P = 0.0054) after just one IA session in our patients with MS. Furthermore, time-courses of sIL-2R in responders and non-responders showed a significant difference (P = 0.03; Figure 2C). Sample dilution in the patients' circulation due to IA was excluded by laboratory follow-ups of hematocrit and albumin in serum.

Figure 2.

Clinical chemistry. Time-courses of (A) IgG; (B) C3c and (C) sIL-2R. sIL-2R is shown in responders (blue) and non-responders (red). Box plots: sign: significant (pairwise comparison to baseline).

Proteomic Data

Our proteomic investigation allowed the identification of 41 proteins with a peptide mass fingerprinting-score >65 in eluates of IA columns. We could identify apolipoproteins, hemorheologically relevant proteins, immunologically relevant proteins, myelin-related proteins and others. A representative two-dimensional gel is shown in Figure 3A and results are summarized in Table 3.

Figure 3.

Protein pattern of the eluate from the tryptophan column after the first immunoadsorption treatment in a single patient analyzed by two-dimensional gel electrophoresis. (A) The protein spots were visualized by Flamingo fluorescence staining. (B) Time-course of plasma myelin basic protein fragment (molecular mass approximately 21 kDa) and soluble CD5L levels determined by western blot from a single patient with MS (upper panels) and densitometric analyses with baseline values set to 100% in the plasma of all 11 treated patients with MS before, during and after IA (lower panels). sign: significant (pairwise comparison to baseline).

Amongst all identified proteins, soluble CD5L and the myelin basic protein (MBP) fragment were quantitatively analyzed in patients' sera by western blots using specific antibodies (Figure 3B). The baseline value was set to 100% and follow-up values were given in percent of baseline. Plasma MBP levels significantly decreased during the first IA session to 46.4 ± 15.0% (P < 0.001) and remained low even in the post-IA control at day 60 ± 10. In parallel, soluble CD5L (sCD5L) levels decreased to 50.5 ± 15.0% (P < 0.001) after the first IA and remained subsequently low. Time-courses of sCD5L and MBP are shown in Figure 3B.

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