Prolonged Immunoadsorption Eases Lupus Nephritis
ATLANTA—Prolonged immunoadsorption (IAS) decreases proteinuria and leads to sustained stabilization of lupus nephritis in patients with highly active systemic lupus erythematosus (SLE), according to long-term results of a small Austrian study. The treatment did not result in tumors, anaphylaxis, or orthostatic events.
Nearly 70% of patients were in remission at the end of the study's observation period, said lead investigator Georg Stummvoll, MD, Professor of Nephrology at the University of Vienna.
He added that the treatment is expensive, but “this is for patients who are not helped in any other way.”
Dr. Stummvoll presented study findings at the American College of Rheumatology annual meeting.
SLE is characterized by pathogenic autoantibodies and immune complexes that can effectively be removed by extracorporeal procedures, such as IAS, Dr. Stummvoll explained. “The advantage of this approach over plasmapheresis or plasma exchange is that you reinfuse everything except for the immunoglobulin,” he said. “You receive the treatment daily the first two weeks, then the patient comes back for two sessions over the next two weeks.”
In a previous study, he and his colleagues observed that after one year of IAS there was a reduction of proteinuria, disease activity, and pre-treatment autoantibody levels in patients with highly active SLE and renal involvement. Antibody removal, however, does not block the formation of new autoantibodies.
The new findings emerged from a study of 13 patients with highly active SLE accompanied by lupus nephritis. They were placed on IAS therapy because intravenous cyclophosphamide was contraindicated or ineffectual. During IAS therapy, oral immunosuppression and ACE inhibitors or angiotensin receptor blockers were kept constant. Steroids were tapered as clinically feasible.
After a mean follow-up of 6.7 years, mean protein excretion decreased from 2.0 to 0.9 g/day and creatinine clearance increased to normal ranges in all patients. Complete remission (defined as protein excretion below 0.5 g/day) was achieved in nine patients (69%). One patient flared and discontinued therapy. Ten patients (77%) are still receiving IAS therapy.
Dr. Stummvoll noted that in two patients, IAS was stopped because of a sustained response. “It appears that in some patients it may be possible to treat for several months and then just let them stop it. You can increase the intervals, lower the frequency, and then stop it. You can always start it again if necessary. It is expensive but it is not any more expensive than using a biological agent.”
The adverse effect profile quite good, he said. Severe infections and severe flares rarely occurred. The rates of both of these complications were 0.1 per patient year.