Journal of Clinical Apheresis 00:00–00 (2015)
Therapeutic Effect of Double-Filtration Plasmapheresis Combined With Methylprednisolone to Treat Diffuse Proliferative Lupus Nephritis MinXia Li,1,2 YuanDa Wang,1 Qiang Qiu,1 RiBao Wei,1* YuWei Gao,1 Li Zhang,1 Yong Wang,1 XueGuang Zhang,1 and XiangMei Chen1* 1
Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases., Beijing, China 2 Department of Nephrology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China Objective: The efficacy of double-filtration plasmapheresis (DFPP), combined with methylprednisolone, to treat diffuse proliferative lupus nephritis (LN) was studied. Methods: Twenty-four patients who were admitted to the hospital and diagnosed with diffuse proliferative LN (LN Class IV-G(A)) through renal biopsy from 2011 to 2013 were recruited as the study subjects. The patients’ clinical manifestations were nephritic syndrome and/or renal insufficiency. The pathological features were glomerular diffuse proliferative lesions. The patients were divided into two groups: the treatment group and the control group, with 12 patients in each group. The patients in the treatment group were first treated with DFPP combined with methylprednisolone (0.8–1.0 mg/kg/day); subsequently, they were put on methylprednisolone therapy only. The patients in the control group were first put on methylprednisolone pulse therapy (500– 1,000 mg) for 3 days; subsequently, they were treated with methylprednisolone (0.8–1.0 mg/kg/day) combined with mycophenolate mofetil (1.5 g/day). The patients were observed for 24 months. Levels of hemoglobin, platelet, albumin, serum creatinine, 24-h urinary protein, serum C3, antinuclear antibody (ANA), anti-dsDNA, and anti-Smith were measured at 0, 3, 6, 12, and 24 months. Complete remission and recurrence standards were established. The total dosages of methylprednisolone were calculated. Repeated renal biopsy was performed on several patients. Results: There was no statistical significance in the baseline conditions of the treatment and the control groups. For the treatment group, no plasmapheresis-related complications occurred. The two groups showed no significant difference in complete remission. The patients’ edema and serous effusion resolved, urine volume, serum creatinine, and albumin levels returned to normal, urine protein decreased in treatment group more rapidly than the patients in the control group. The mean dose of methylprednisolone received in the treatment group was lower than in the control group. The complement C3 levels in the treatment group were significantly higher than in the control group. The recurrence rate in the treatment group was lower than in the control group. Repeated renal biopsies on several patients in the treatment group indicated that their pathology improved significantly, changing from LN (IV) to LN(II–III). Conclusions: Appropriate application of DFPP combined with glucocorticoid therapy could accelerate the remission of diffuse proliferative LN, reduce overall glucocorticoid dosage, prevent recurrence, and maintain C3 level in a higher level. J. Clin. Apheresis 00:000–000, 2015. C 2015 Wiley Periodicals, Inc. V Key words: double-filtration plasmapheresis; lupus nephritis; methylprednisolone; complement C3
*Correspondence to: XiangMei Chen, Department of Nephrology, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital. No 28, Fuxing road, Haidian district, Beijing, China. E-mail: [email protected] or RiBao Wei, Department of Nephrology, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital. No 28, Fuxing road, Haidian district, Beijing, China. E-mail: [email protected] Contract grant sponsor: “Significant creation of new drugs” of National Science and Major Project; Contract grant number: 2010ZX09102204. Contract grant sponsor: National Natural Sciences Foundation of China; Contract grant number: 81072914, 81273968. Contract grant sponsor: Ministerial projects of the National Working Commission on Aging; Contract grant number: QLB2014W002. Contract grant sponsor: Medicine and Health Foundation of PLA; Contract grant number: 10ZYZ255. Received 20 December 2014; Accepted 7 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21408 C 2015 Wiley Periodicals, Inc. V
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INTRODUCTION
Lupus nephritis (LN) is the most common complication of systemic lupus erythematosus (SLE) and also the most common secondary glomerular disease in China. The clinical manifestation of diffuse proliferative LN is nephritic syndrome or even abnormal renal function, multiple organ damage. Ordinarily, aggressive and appropriate steroid and immunosuppressive therapies are necessary; however, these patients are generally combined with infection, polyserositis, blood glucose elevation, and osteoporosis. Using high doses of steroids to treat the acute stages is associated with increased risks and might reduce the therapeutic effect. Plasmapheresis has been used to treat immunologic kidney diseases for 40 years. One study with a small sample size showed a good therapeutic effect for plasmapheresis in treating LN combined with such critical conditions as pulmonary hemorrhage, lupus encephalopathy, thrombotic microangiopathy, and antiphospholipid antibody syndrome [1]. Herein, our study was carried out to observe the efficacy and safety of the therapeutic regimen of double-filtration plasmapheresis (DFPP) combined with steroid to treat patients with diffuse proliferative LN. MATERIALS AND METHODS Subjects and Grouping
Twenty-four patients who were admitted to Chinese PLA General Hospital and diagnosed with diffuse proliferative LN for the first time (LN Class IV-G (A)) from 2011 to 2013 were recruited in this study. Inclusion criteria: patients with the clinical pathological diagnosis of diffuse proliferative LN [2]; the pathological manifestations are diffuse proliferation of glomerular cells, formation of crescents, and a large amount of subendothelial immune complex deposition; the clinical manifestation is nephritic syndrome. Exclusion criteria: patients with diffuse proliferative LN combined with such lesions as membranous and chronic sclerosis; coagulation abnormalities; allergic to blood plasma; and acute renal failure requiring hemodialysis. Patients who were intolerant to a large quantity of steroid (e.g., patients with hyperglycemia, obesity, femoral neck fracture, or recent cytomegalovirus (CMV) infection) were recommended to join the treatment group. All patients in the two groups signed informed consent forms. Treatment regimens: The patients in the treatment group were first treated with DFPP combined with methylprednisolone (0.8–1.0 mg/kg/day). Then, the patients were continued on methylprednisolone. The patients in the control group were first put on methylprednisolone pulse therapy (0.5–1 g/day) for 3 days. Subsequently, they were treated with methylprednisoJournal of Clinical Apheresis DOI 10.1002/jca
lone (0.8–1.0 mg/kg/day) combined with mycophenolate mofetil (MMF, 1.5 g/day). The minimum maintenance dose of methylprednisolone was 6–8 mg. DFPP Treatment Regimen
A temporary right-sided internal jugular vein indwelling catheter was placed in the patients. A BBRAUN Dialog Plasma Separator (B.Braun Melsungen AG, Germany) was used. A heparin or low-molecularweight heparin anticoagulant was selected. An OP08W Plasma Separator and a Cascadeflo EC-30W Plasma Component Separator (Asahi Medical Co., Ltd., Japan) were used (blood flow: 150 mL/min; plasma flow: 30 mL/min). Fresh frozen plasma was used as the replacement fluid. Plasmapheresis was conducted every other day for a total of three times. The exchange volume for each time 5 1/5 EPV, estimated plasma volume (EPV) 5 (1 2 Hct) (b 1 cW), Hct: Hematocrit; W: weight (kg), b: 1,530 (male), 864 (female); C: 41(male), 47.2 (female). The exchange volume was 1.58 6 0.44 L. After treatment, the temporary right-sided internal jugular vein indwelling catheter was removed. Therapeutic Effect Observation
Clinical manifestations were observed, and levels of hemoglobin, platelets, albumin, serum creatinine, 24-h urinary protein, antinuclear antibody (ANA), antidsDNA antibody, anti-Smith antibody, and complement C3 were measured at 0, 3, 6, 12, and 24 months. Therapeutic Effect Evaluation
(1) Complete remission was defined by the following clinical manifestations: the 24-h urinary protein excretion less than 0.3 g; normal serum albumin level and renal function tests; negative anti-dsDNA antibody testing. (2) Recurrence was defined by the following criteria: diffuse proliferative LN reoccurred within 12 weeks after complete remission; the 24-h urinary protein excretion was [mt]1 g; the anti-dsDNA antibody testing became positive. (3) Daily mean therapeutic methylprednisolone dose: total dose of methylprednisolone/treatment days Statistical Analysis
A form of mean 6 standard deviation (SD) was used to represent normally distribution data, including body mass index (BMI), mean arterial pressure, C3, C4, serum creatinine, urea, uric acid, serum albumin, 24-h urinary protein excretion, quantitative indices (e.g., pathological activity index), etc. The t test was used for statistical analysis. Fisher’s exact test was used for
Therapeutic Effect of DFPP in Diffuse Proliferative LN
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TABLE I. Comparison Between the Baseline Conditions of the Patients in the Treatment and Control Groups
Age (years) Male (%) BMI (kg/m2) Months of disease before biopsy Mean BP (mmHg) Edema (cases) Serous effusion (cases) Hemoglobin(g/L) Platelet(109/L) ALB (g/L) Scr (mmol/L) SLEDAI ANA Anti-dsDNA Anti-smith C3 (mg/dL) C4 (mg/dL) 24 h UPR (g) Crescent (%) AI CI
Treatment group (n 5 12)
Control group (n 5 12)
P
25.16 6 4.98 25% 22.2 6 1.71 0.5–60 92.26 6 16.12 12 12 86.6 6 11.01 146.85 6 50.79 22.77 6 5.30 112.6 6 47.70 24.0 6 2.68 1:1,000–1:1,280 1:1–1:10 3 26.02 6 8.62 4.18 6 2.04 6.09 6 1.45 3.0–7.4 8.57 6 1.7 1.20 6 0.63
22.71 6 2.92 25% 20.1 6 1.50 0.5–48 106.25 6 18.03 12 8 101.8 6 12.47 139.0 6 91.68 23.12 6 5.56 94.82 6 46.70 22.14 6 3.76 1:640–1:1,000 1:1–1:10 3 24.68 6 9.93 4.10 6 2.20 5.17 6 1.63 1.2–7.7 7.67 6 2.58 1.44 6 0.88
0.828 >0.05 0.04 0.839 0.167 >0.05 0.317 0.075 0.849 0.915 0.513 0.336 0.347 0.303 >0.05 0.816 0.95 0.312 0.225 0.466 0.164
BMI: body mass index; BP: blood pressure; ALB: albumin; Scr: serum creatinine concentration; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; ANA: antinuclear antibody; 24h UPR: 24-h urinary protein; AI: Pathological activity index: CI: Pathological chronic Index
rate and constituent ratio comparisons. The Mann– Whitney test was used for non-normally distributed data. Statistical significance was assigned at P < 0.05. RESULTS Baseline Demographics
Eighteen females and six males were admitted. The ages of the patients ranged from 18 to 31 years old, and the mean age was 21.72 6 3.45 years old. There was no difference between the patients in the two groups in terms of age, sex, mean arterial pressure, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, edema, serous effusion, hemoglobin, platelets, serum albumin, serum creatinine, immune index, urinary protein excretion, renal pathological activity index, and chronicity index. The BMI of the treatment group was higher than in the control group. In the treatment group, four patients had CMV infections or pneumonia, one patient had hyperglycemia, and one patient had a recent fracture (Table I)
Therapeutic Effect Observation Clinical manifestations
For the treatment group, the patients’ edema resolved, their urine volume returned to normal, and their serum creatinine and albumin levels returned to normal more rapidly. Their serous effusion also resolved significantly
more quickly than in the patients in the control group (P < 0.01). The patients with CMV infections and pneumonia recovered from their infections; the conditions of the patient with hyperglycemia and the patient with a recent fracture did not deteriorate. The complete remission rate in the treatment group was higher than in the control group at 3 months (P < 0.05), but there is no differences at 24 months (P > 0.05); the number of cases of recurrence in the treatment group was also lower than in the control group (P < 0.05). The mean steroid dose used in the treatment group was significantly lower than in the control group (P 5 0.01) (Table II). No DFPP-related complications occurred. TABLE II. Comparison Between the Clinical Remission of the Patients in the Treatment and Control Groups
Edema recovery (day) Urine>1500 mL (day) Scr recovery (day) Albumin>30 (day) Serous effusion (day) Complete remission (3 months) Complete remission (24 months) Recurrence Daily mean methylprednisolone (tablets/day)
Treatment group (n 5 12)
Control group (n 5 12)
P
6.5 8.5 10 14 13.5 8
14 11.5 24.5 34 18 4
0.00 0.00 0.00 0.00 0.00 0.01
11
7
>0.05
1 3.40 6 0.35
3 4.60 6 0.29
0.05). Variation of 24-h urinary protein
The 24-h urinary protein level decreased much faster in the patients in the treatment group than in the control group (Fig. 1). Variation of complements
During follow-up visits, the complement C3 levels in the patients in the treatment group were significantly higher than those of the patients in the control group (Fig. 2). Repeated Renal Biopsy
Repeated renal biopsy was conducted in three patients in the treatment group. Twenty-four months after treatment, the crescents and “wire loop” disappeared, and the cell proliferation was significantly reduced; only small amounts of immunoglobulin G (IgG) and IgA deposition were observed on immunofluorescence testing (Figs. 3 and 4). DISCUSSION
SLE is a complicated autoimmune disease. LN is one of the most common clinical manifestations of SLE. The pathological manifestations of diffuse proliferative LN are proliferation inside and outside of over 50% of the glomerular vessels, the formation of crescents and diffuse subendothelial immune complex deposition. Removing autoantibodies and immune complexes is the primary objective of SLE therapy. DFPP separates the patients’ plasma twice and then retransfuses the plasma from which the pathogenic factors have been removed, returning the viable blood components back to the patient’s body. DFPP can quickly lower the concentration of pathogenic immunoglobulins in the blood; in addition, a large amount of fresh plasma replacement is unnecessary. One prior study showed that DFPP combined with steroid therapy and cyclophosphamides combined with Journal of Clinical Apheresis DOI 10.1002/jca
steroid therapy were equally effective in treating proliferative LN [3]. In addition, DFPP combined with steroid therapy significantly accelerated the decrease in the urinary protein level, and the recurrence rate in the long-term plasmapheresis group was lower than in the short-term treatment group [4]. In the present study, we also discovered that the urinary protein level decreased more rapidly and DFPP treatment has a lower recurrence rate in the treatment group than in the control group. Especially in the first 3 months of the “induction therapy” for the patients in the treatment group, their urinary protein level decreased, while their plasma albumin level increased. Houssiau et al. [5] conducted long-term follow-up on 90 cases of proliferative LN, and they found that early response to the treatment was a better predictive factor of long-term prognosis. The comparison between patients with relatively good long-term prognoses and patients with relatively poor prognoses showed that the urinary protein level decreased by 50% within 6 months in 72% of the patients with relatively good long-term prognoses but in only 40% of the patients with relatively poor prognoses. The multivariate analysis revealed that the odds of a better prognosis were six times higher for patients whose urinary protein level decreased to 1 g within 6 months compared with patients whose urinary protein level was more than 1 g. Therefore, it is necessary to decrease the urinary protein level of LN as soon as possible to obtain a better prognosis. Lewis et al. in their randomized controlled studies found that additional plasmapheresis therapy did not improve the outcome than the combination of prednisone and short-term cyclophosphamide [6]. After ten years, another randomized controlled study also showed that compared with cyclophosphamide treatment of proliferative LN alone, plasma exchange combined with cyclophosphamide, although you can get faster relief, but it does not improve long-term prognosis [7]. The study also found that after 24-months of
Fig. 2. Variation of complement C3 levels. Starting at the 6th month, a difference in the complement C3 levels between the patients in the two groups emerged (*P < 0.05; DP > 0.05).
Therapeutic Effect of DFPP in Diffuse Proliferative LN
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Fig. 3. Renal biopsy pathology results before treatment. (A: PAS 2003, B: PAM 4003, C: IgG IF 2003, D: IgA IF 2003, E: IgM IF 2003, F: C3 IF 2003, G: C4 IF 2003, H: C1q IF 2003, I: Fib IF 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. Repeat renal biopsy results for patients in the treatment group. (A: PAS 2003, B: PAM 2003, C: IgG IF 2003, D: IgA IF 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Journal of Clinical Apheresis DOI 10.1002/jca
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follow-up, the two groups showed no significant difference in complete remission. But, this may be because the condition of patients in the treatment group is more critical. Other good outcomes were discovered that the early and long-term mean dose of methylprednisolone received was much lower in the treatment group than in the control group. The repeated renal biopsies on a few of the patients in treatment group showed that the pathological changes due to LN had improved to less severe classes (Class IV to Class II and Class III). The complement C3 level decreases in 68% of patients with LN, and the complement C3 level is relatively highly correlated to clinical disease activity. There is also a correlation between the increase in the metabolic components of various complements in the serum and clinical SLE activity; the complement C3 level is useful to monitor disease activity [8]. It was discovered in the present study that the recovery speed of the C3 level in the treatment group was faster than in the control group; after 24 months of follow-up, the number of the patients in the treatment group with a normal C3 level was much higher than in the control group. It was also discovered in past studies that the percentage of patients whose C3 level recovered to normal was higher among the patients who were treated with plasmapheresis combined with cyclophosphamide [4], possibly because plasmapheresis quickly removed immune complexes and quickly inhibited the cascade reaction of complement activation. The present study showed that the reasonable use DFPP combined with glucocorticoid to treat diffuse proliferative LN was safe and effective. Although, DFPP combined glucocorticoid and MMF combined with glucocorticoid have no significant difference in complete remission rate in long term. DFPP combined with glucocorticoid could reduce urinary protein levels rapidly, maintain normal complement levels, and reduce the dose of glucocorticoid required. Thus, to treat diffuse proliferative LN in serious condition, if the patient does not tolerate the impact of glucocorticoid pulse treatment, temporarily unable to add immunosuppression, DFPP may be a good choice.
Journal of Clinical Apheresis DOI 10.1002/jca
AUTHOR CONTRIBUTION
Li MX and Wang YD performed all trials, analysis data and wrote the manuscript. QIU Q, Gao YW, Zhang L, Wang Y, Zhang XG, technically assisted in performing a portion of the experiments. RiBao Wei designed and supervised the project. REFERENCES 1. Pagnoux C, Korach JM, Guillevin L. Indications for plasma exchange in systemic lupus erythematosus in 2005. Lupus 2005; 14:871–877. 2. Weening JJ1, D’Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, Hill P, Jennette JC, Kong NC, Lesavre P, Lockshin M, Looi LM, Makino H, Moura LA, Nagata M. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004;15:241– 250. 3. Nakamura T, Ushiyama C, Hara M, Osada S, Ugai K, Shimada N, Hayashi K, Ebihara I, Koide H. Comparative effects of plasmapheresis and intravenous cyclophosphamide on urinary podocyte excretion in patients with proliferative lupus nephritis. Clin Nephrol 2002;57:108–113. 4. Yamaji K, Kim YJ, Tsuda H, Takasaki Y. Long-term clinical outcomes of synchronized therapy with plasmapheresis and intravenous cyclophosphamide pulse therapy in the treatment of Steroid-resistant lupus nephritis. Ther Apher Dial 2008;12:298– 305. 5. Houssiau FA, Vasconcelos C, D’Cruz D, Sebastiani GD, de Ramon Garrido E, Danieli MG, Abramovicz D, Blockmans D, Mathieu A, Direskeneli H, Galeazzi M, G€ul A, Levy Y, Petera P, Popovic R, Petrovic R, Sinico RA, Cattaneo R, Font J, Depresseux G, Cosyns JP, Cervera R. Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: lessons from long-term followup of patients in the Euro-lupus nephritis trial. Arthritis Rheum 2004;50:3934–3940. 6. Lewis EJ, Hunsicker LG, Lan SP, Rohde RD, Lachin JM. A controlled trial of plasmapheresis therapy in severe lupus nephritis. The lupus nephritis collaborative study group. N Engl J Med 1992;326:1373–1379. 7. Danieli MG, Palmieri C, Salvi A, Refe MC, Strusi AS, Danieli G. Synchronised therapy and high-dose cyclophosphamide in proliferative lupus nephritis. J Clin Apher 2002;17:72–77. 8. Buyon JP, Tamerius J, Belmont HM, Abramson SB. Assessment of disease activity and impending flare in patients with systemic lupus erythematosus. Comparison of the use of complement split products and conventional measurements of complement. Arthritis Rheum 1992;35:1028–1037.
Therapeutic Effect of Double-Filtration Plasmapheresis Combined With Methylprednisolone to Treat Diffuse Proliferative Lupus Nephritis MinXia Li,1,2 YuanDa Wang,1 Qiang Qiu,1 RiBao Wei,1* YuWei Gao,1 Li Zhang,1 Yong Wang,1 XueGuang Zhang,1 and XiangMei Chen1* 1
Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases., Beijing, China 2 Department of Nephrology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China Objective: The efficacy of double-filtration plasmapheresis (DFPP), combined with methylprednisolone, to treat diffuse proliferative lupus nephritis (LN) was studied. Methods: Twenty-four patients who were admitted to the hospital and diagnosed with diffuse proliferative LN (LN Class IV-G(A)) through renal biopsy from 2011 to 2013 were recruited as the study subjects. The patients’ clinical manifestations were nephritic syndrome and/or renal insufficiency. The pathological features were glomerular diffuse proliferative lesions. The patients were divided into two groups: the treatment group and the control group, with 12 patients in each group. The patients in the treatment group were first treated with DFPP combined with methylprednisolone (0.8–1.0 mg/kg/day); subsequently, they were put on methylprednisolone therapy only. The patients in the control group were first put on methylprednisolone pulse therapy (500– 1,000 mg) for 3 days; subsequently, they were treated with methylprednisolone (0.8–1.0 mg/kg/day) combined with mycophenolate mofetil (1.5 g/day). The patients were observed for 24 months. Levels of hemoglobin, platelet, albumin, serum creatinine, 24-h urinary protein, serum C3, antinuclear antibody (ANA), anti-dsDNA, and anti-Smith were measured at 0, 3, 6, 12, and 24 months. Complete remission and recurrence standards were established. The total dosages of methylprednisolone were calculated. Repeated renal biopsy was performed on several patients. Results: There was no statistical significance in the baseline conditions of the treatment and the control groups. For the treatment group, no plasmapheresis-related complications occurred. The two groups showed no significant difference in complete remission. The patients’ edema and serous effusion resolved, urine volume, serum creatinine, and albumin levels returned to normal, urine protein decreased in treatment group more rapidly than the patients in the control group. The mean dose of methylprednisolone received in the treatment group was lower than in the control group. The complement C3 levels in the treatment group were significantly higher than in the control group. The recurrence rate in the treatment group was lower than in the control group. Repeated renal biopsies on several patients in the treatment group indicated that their pathology improved significantly, changing from LN (IV) to LN(II–III). Conclusions: Appropriate application of DFPP combined with glucocorticoid therapy could accelerate the remission of diffuse proliferative LN, reduce overall glucocorticoid dosage, prevent recurrence, and maintain C3 level in a higher level. J. Clin. Apheresis 00:000–000, 2015. C 2015 Wiley Periodicals, Inc. V Key words: double-filtration plasmapheresis; lupus nephritis; methylprednisolone; complement C3
*Correspondence to: XiangMei Chen, Department of Nephrology, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital. No 28, Fuxing road, Haidian district, Beijing, China. E-mail: [email protected] or RiBao Wei, Department of Nephrology, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital. No 28, Fuxing road, Haidian district, Beijing, China. E-mail: [email protected] Contract grant sponsor: “Significant creation of new drugs” of National Science and Major Project; Contract grant number: 2010ZX09102204. Contract grant sponsor: National Natural Sciences Foundation of China; Contract grant number: 81072914, 81273968. Contract grant sponsor: Ministerial projects of the National Working Commission on Aging; Contract grant number: QLB2014W002. Contract grant sponsor: Medicine and Health Foundation of PLA; Contract grant number: 10ZYZ255. Received 20 December 2014; Accepted 7 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21408 C 2015 Wiley Periodicals, Inc. V
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Li et al.
INTRODUCTION
Lupus nephritis (LN) is the most common complication of systemic lupus erythematosus (SLE) and also the most common secondary glomerular disease in China. The clinical manifestation of diffuse proliferative LN is nephritic syndrome or even abnormal renal function, multiple organ damage. Ordinarily, aggressive and appropriate steroid and immunosuppressive therapies are necessary; however, these patients are generally combined with infection, polyserositis, blood glucose elevation, and osteoporosis. Using high doses of steroids to treat the acute stages is associated with increased risks and might reduce the therapeutic effect. Plasmapheresis has been used to treat immunologic kidney diseases for 40 years. One study with a small sample size showed a good therapeutic effect for plasmapheresis in treating LN combined with such critical conditions as pulmonary hemorrhage, lupus encephalopathy, thrombotic microangiopathy, and antiphospholipid antibody syndrome [1]. Herein, our study was carried out to observe the efficacy and safety of the therapeutic regimen of double-filtration plasmapheresis (DFPP) combined with steroid to treat patients with diffuse proliferative LN. MATERIALS AND METHODS Subjects and Grouping
Twenty-four patients who were admitted to Chinese PLA General Hospital and diagnosed with diffuse proliferative LN for the first time (LN Class IV-G (A)) from 2011 to 2013 were recruited in this study. Inclusion criteria: patients with the clinical pathological diagnosis of diffuse proliferative LN [2]; the pathological manifestations are diffuse proliferation of glomerular cells, formation of crescents, and a large amount of subendothelial immune complex deposition; the clinical manifestation is nephritic syndrome. Exclusion criteria: patients with diffuse proliferative LN combined with such lesions as membranous and chronic sclerosis; coagulation abnormalities; allergic to blood plasma; and acute renal failure requiring hemodialysis. Patients who were intolerant to a large quantity of steroid (e.g., patients with hyperglycemia, obesity, femoral neck fracture, or recent cytomegalovirus (CMV) infection) were recommended to join the treatment group. All patients in the two groups signed informed consent forms. Treatment regimens: The patients in the treatment group were first treated with DFPP combined with methylprednisolone (0.8–1.0 mg/kg/day). Then, the patients were continued on methylprednisolone. The patients in the control group were first put on methylprednisolone pulse therapy (0.5–1 g/day) for 3 days. Subsequently, they were treated with methylprednisoJournal of Clinical Apheresis DOI 10.1002/jca
lone (0.8–1.0 mg/kg/day) combined with mycophenolate mofetil (MMF, 1.5 g/day). The minimum maintenance dose of methylprednisolone was 6–8 mg. DFPP Treatment Regimen
A temporary right-sided internal jugular vein indwelling catheter was placed in the patients. A BBRAUN Dialog Plasma Separator (B.Braun Melsungen AG, Germany) was used. A heparin or low-molecularweight heparin anticoagulant was selected. An OP08W Plasma Separator and a Cascadeflo EC-30W Plasma Component Separator (Asahi Medical Co., Ltd., Japan) were used (blood flow: 150 mL/min; plasma flow: 30 mL/min). Fresh frozen plasma was used as the replacement fluid. Plasmapheresis was conducted every other day for a total of three times. The exchange volume for each time 5 1/5 EPV, estimated plasma volume (EPV) 5 (1 2 Hct) (b 1 cW), Hct: Hematocrit; W: weight (kg), b: 1,530 (male), 864 (female); C: 41(male), 47.2 (female). The exchange volume was 1.58 6 0.44 L. After treatment, the temporary right-sided internal jugular vein indwelling catheter was removed. Therapeutic Effect Observation
Clinical manifestations were observed, and levels of hemoglobin, platelets, albumin, serum creatinine, 24-h urinary protein, antinuclear antibody (ANA), antidsDNA antibody, anti-Smith antibody, and complement C3 were measured at 0, 3, 6, 12, and 24 months. Therapeutic Effect Evaluation
(1) Complete remission was defined by the following clinical manifestations: the 24-h urinary protein excretion less than 0.3 g; normal serum albumin level and renal function tests; negative anti-dsDNA antibody testing. (2) Recurrence was defined by the following criteria: diffuse proliferative LN reoccurred within 12 weeks after complete remission; the 24-h urinary protein excretion was [mt]1 g; the anti-dsDNA antibody testing became positive. (3) Daily mean therapeutic methylprednisolone dose: total dose of methylprednisolone/treatment days Statistical Analysis
A form of mean 6 standard deviation (SD) was used to represent normally distribution data, including body mass index (BMI), mean arterial pressure, C3, C4, serum creatinine, urea, uric acid, serum albumin, 24-h urinary protein excretion, quantitative indices (e.g., pathological activity index), etc. The t test was used for statistical analysis. Fisher’s exact test was used for
Therapeutic Effect of DFPP in Diffuse Proliferative LN
3
TABLE I. Comparison Between the Baseline Conditions of the Patients in the Treatment and Control Groups
Age (years) Male (%) BMI (kg/m2) Months of disease before biopsy Mean BP (mmHg) Edema (cases) Serous effusion (cases) Hemoglobin(g/L) Platelet(109/L) ALB (g/L) Scr (mmol/L) SLEDAI ANA Anti-dsDNA Anti-smith C3 (mg/dL) C4 (mg/dL) 24 h UPR (g) Crescent (%) AI CI
Treatment group (n 5 12)
Control group (n 5 12)
P
25.16 6 4.98 25% 22.2 6 1.71 0.5–60 92.26 6 16.12 12 12 86.6 6 11.01 146.85 6 50.79 22.77 6 5.30 112.6 6 47.70 24.0 6 2.68 1:1,000–1:1,280 1:1–1:10 3 26.02 6 8.62 4.18 6 2.04 6.09 6 1.45 3.0–7.4 8.57 6 1.7 1.20 6 0.63
22.71 6 2.92 25% 20.1 6 1.50 0.5–48 106.25 6 18.03 12 8 101.8 6 12.47 139.0 6 91.68 23.12 6 5.56 94.82 6 46.70 22.14 6 3.76 1:640–1:1,000 1:1–1:10 3 24.68 6 9.93 4.10 6 2.20 5.17 6 1.63 1.2–7.7 7.67 6 2.58 1.44 6 0.88
0.828 >0.05 0.04 0.839 0.167 >0.05 0.317 0.075 0.849 0.915 0.513 0.336 0.347 0.303 >0.05 0.816 0.95 0.312 0.225 0.466 0.164
BMI: body mass index; BP: blood pressure; ALB: albumin; Scr: serum creatinine concentration; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; ANA: antinuclear antibody; 24h UPR: 24-h urinary protein; AI: Pathological activity index: CI: Pathological chronic Index
rate and constituent ratio comparisons. The Mann– Whitney test was used for non-normally distributed data. Statistical significance was assigned at P < 0.05. RESULTS Baseline Demographics
Eighteen females and six males were admitted. The ages of the patients ranged from 18 to 31 years old, and the mean age was 21.72 6 3.45 years old. There was no difference between the patients in the two groups in terms of age, sex, mean arterial pressure, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, edema, serous effusion, hemoglobin, platelets, serum albumin, serum creatinine, immune index, urinary protein excretion, renal pathological activity index, and chronicity index. The BMI of the treatment group was higher than in the control group. In the treatment group, four patients had CMV infections or pneumonia, one patient had hyperglycemia, and one patient had a recent fracture (Table I)
Therapeutic Effect Observation Clinical manifestations
For the treatment group, the patients’ edema resolved, their urine volume returned to normal, and their serum creatinine and albumin levels returned to normal more rapidly. Their serous effusion also resolved significantly
more quickly than in the patients in the control group (P < 0.01). The patients with CMV infections and pneumonia recovered from their infections; the conditions of the patient with hyperglycemia and the patient with a recent fracture did not deteriorate. The complete remission rate in the treatment group was higher than in the control group at 3 months (P < 0.05), but there is no differences at 24 months (P > 0.05); the number of cases of recurrence in the treatment group was also lower than in the control group (P < 0.05). The mean steroid dose used in the treatment group was significantly lower than in the control group (P 5 0.01) (Table II). No DFPP-related complications occurred. TABLE II. Comparison Between the Clinical Remission of the Patients in the Treatment and Control Groups
Edema recovery (day) Urine>1500 mL (day) Scr recovery (day) Albumin>30 (day) Serous effusion (day) Complete remission (3 months) Complete remission (24 months) Recurrence Daily mean methylprednisolone (tablets/day)
Treatment group (n 5 12)
Control group (n 5 12)
P
6.5 8.5 10 14 13.5 8
14 11.5 24.5 34 18 4
0.00 0.00 0.00 0.00 0.00 0.01
11
7
>0.05
1 3.40 6 0.35
3 4.60 6 0.29
0.05). Variation of 24-h urinary protein
The 24-h urinary protein level decreased much faster in the patients in the treatment group than in the control group (Fig. 1). Variation of complements
During follow-up visits, the complement C3 levels in the patients in the treatment group were significantly higher than those of the patients in the control group (Fig. 2). Repeated Renal Biopsy
Repeated renal biopsy was conducted in three patients in the treatment group. Twenty-four months after treatment, the crescents and “wire loop” disappeared, and the cell proliferation was significantly reduced; only small amounts of immunoglobulin G (IgG) and IgA deposition were observed on immunofluorescence testing (Figs. 3 and 4). DISCUSSION
SLE is a complicated autoimmune disease. LN is one of the most common clinical manifestations of SLE. The pathological manifestations of diffuse proliferative LN are proliferation inside and outside of over 50% of the glomerular vessels, the formation of crescents and diffuse subendothelial immune complex deposition. Removing autoantibodies and immune complexes is the primary objective of SLE therapy. DFPP separates the patients’ plasma twice and then retransfuses the plasma from which the pathogenic factors have been removed, returning the viable blood components back to the patient’s body. DFPP can quickly lower the concentration of pathogenic immunoglobulins in the blood; in addition, a large amount of fresh plasma replacement is unnecessary. One prior study showed that DFPP combined with steroid therapy and cyclophosphamides combined with Journal of Clinical Apheresis DOI 10.1002/jca
steroid therapy were equally effective in treating proliferative LN [3]. In addition, DFPP combined with steroid therapy significantly accelerated the decrease in the urinary protein level, and the recurrence rate in the long-term plasmapheresis group was lower than in the short-term treatment group [4]. In the present study, we also discovered that the urinary protein level decreased more rapidly and DFPP treatment has a lower recurrence rate in the treatment group than in the control group. Especially in the first 3 months of the “induction therapy” for the patients in the treatment group, their urinary protein level decreased, while their plasma albumin level increased. Houssiau et al. [5] conducted long-term follow-up on 90 cases of proliferative LN, and they found that early response to the treatment was a better predictive factor of long-term prognosis. The comparison between patients with relatively good long-term prognoses and patients with relatively poor prognoses showed that the urinary protein level decreased by 50% within 6 months in 72% of the patients with relatively good long-term prognoses but in only 40% of the patients with relatively poor prognoses. The multivariate analysis revealed that the odds of a better prognosis were six times higher for patients whose urinary protein level decreased to 1 g within 6 months compared with patients whose urinary protein level was more than 1 g. Therefore, it is necessary to decrease the urinary protein level of LN as soon as possible to obtain a better prognosis. Lewis et al. in their randomized controlled studies found that additional plasmapheresis therapy did not improve the outcome than the combination of prednisone and short-term cyclophosphamide [6]. After ten years, another randomized controlled study also showed that compared with cyclophosphamide treatment of proliferative LN alone, plasma exchange combined with cyclophosphamide, although you can get faster relief, but it does not improve long-term prognosis [7]. The study also found that after 24-months of
Fig. 2. Variation of complement C3 levels. Starting at the 6th month, a difference in the complement C3 levels between the patients in the two groups emerged (*P < 0.05; DP > 0.05).
Therapeutic Effect of DFPP in Diffuse Proliferative LN
5
Fig. 3. Renal biopsy pathology results before treatment. (A: PAS 2003, B: PAM 4003, C: IgG IF 2003, D: IgA IF 2003, E: IgM IF 2003, F: C3 IF 2003, G: C4 IF 2003, H: C1q IF 2003, I: Fib IF 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. Repeat renal biopsy results for patients in the treatment group. (A: PAS 2003, B: PAM 2003, C: IgG IF 2003, D: IgA IF 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Journal of Clinical Apheresis DOI 10.1002/jca
6
Li et al.
follow-up, the two groups showed no significant difference in complete remission. But, this may be because the condition of patients in the treatment group is more critical. Other good outcomes were discovered that the early and long-term mean dose of methylprednisolone received was much lower in the treatment group than in the control group. The repeated renal biopsies on a few of the patients in treatment group showed that the pathological changes due to LN had improved to less severe classes (Class IV to Class II and Class III). The complement C3 level decreases in 68% of patients with LN, and the complement C3 level is relatively highly correlated to clinical disease activity. There is also a correlation between the increase in the metabolic components of various complements in the serum and clinical SLE activity; the complement C3 level is useful to monitor disease activity [8]. It was discovered in the present study that the recovery speed of the C3 level in the treatment group was faster than in the control group; after 24 months of follow-up, the number of the patients in the treatment group with a normal C3 level was much higher than in the control group. It was also discovered in past studies that the percentage of patients whose C3 level recovered to normal was higher among the patients who were treated with plasmapheresis combined with cyclophosphamide [4], possibly because plasmapheresis quickly removed immune complexes and quickly inhibited the cascade reaction of complement activation. The present study showed that the reasonable use DFPP combined with glucocorticoid to treat diffuse proliferative LN was safe and effective. Although, DFPP combined glucocorticoid and MMF combined with glucocorticoid have no significant difference in complete remission rate in long term. DFPP combined with glucocorticoid could reduce urinary protein levels rapidly, maintain normal complement levels, and reduce the dose of glucocorticoid required. Thus, to treat diffuse proliferative LN in serious condition, if the patient does not tolerate the impact of glucocorticoid pulse treatment, temporarily unable to add immunosuppression, DFPP may be a good choice.
Journal of Clinical Apheresis DOI 10.1002/jca
AUTHOR CONTRIBUTION
Li MX and Wang YD performed all trials, analysis data and wrote the manuscript. QIU Q, Gao YW, Zhang L, Wang Y, Zhang XG, technically assisted in performing a portion of the experiments. RiBao Wei designed and supervised the project. REFERENCES 1. Pagnoux C, Korach JM, Guillevin L. Indications for plasma exchange in systemic lupus erythematosus in 2005. Lupus 2005; 14:871–877. 2. Weening JJ1, D’Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, Hill P, Jennette JC, Kong NC, Lesavre P, Lockshin M, Looi LM, Makino H, Moura LA, Nagata M. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004;15:241– 250. 3. Nakamura T, Ushiyama C, Hara M, Osada S, Ugai K, Shimada N, Hayashi K, Ebihara I, Koide H. Comparative effects of plasmapheresis and intravenous cyclophosphamide on urinary podocyte excretion in patients with proliferative lupus nephritis. Clin Nephrol 2002;57:108–113. 4. Yamaji K, Kim YJ, Tsuda H, Takasaki Y. Long-term clinical outcomes of synchronized therapy with plasmapheresis and intravenous cyclophosphamide pulse therapy in the treatment of Steroid-resistant lupus nephritis. Ther Apher Dial 2008;12:298– 305. 5. Houssiau FA, Vasconcelos C, D’Cruz D, Sebastiani GD, de Ramon Garrido E, Danieli MG, Abramovicz D, Blockmans D, Mathieu A, Direskeneli H, Galeazzi M, G€ul A, Levy Y, Petera P, Popovic R, Petrovic R, Sinico RA, Cattaneo R, Font J, Depresseux G, Cosyns JP, Cervera R. Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: lessons from long-term followup of patients in the Euro-lupus nephritis trial. Arthritis Rheum 2004;50:3934–3940. 6. Lewis EJ, Hunsicker LG, Lan SP, Rohde RD, Lachin JM. A controlled trial of plasmapheresis therapy in severe lupus nephritis. The lupus nephritis collaborative study group. N Engl J Med 1992;326:1373–1379. 7. Danieli MG, Palmieri C, Salvi A, Refe MC, Strusi AS, Danieli G. Synchronised therapy and high-dose cyclophosphamide in proliferative lupus nephritis. J Clin Apher 2002;17:72–77. 8. Buyon JP, Tamerius J, Belmont HM, Abramson SB. Assessment of disease activity and impending flare in patients with systemic lupus erythematosus. Comparison of the use of complement split products and conventional measurements of complement. Arthritis Rheum 1992;35:1028–1037.
