A pilot study using a staph protein A column (Prosorba) to treat refractory rheumatoid arthritis.

OBJECTIVE: To assess the safety and effectiveness of extracorporeal treatments with protein A (Prosorba) columns in the treatment of patients with severe refractory rheumatoid arthritis (RA) in an open label pilot study. METHODS: Fifteen patients with RA who had failed to respond to 2 or more disease modifying antirheumatic drugs were "washed out" for 1-3 months before enrollment into this 6 month pilot study. The treatment schedule called for patients to receive apheresis treatments across staphylococcal protein A columns once a week for 12 weeks. Clinical evaluations of RA activity, defined by Paulus criteria, were conducted at study enrollment (baseline) and monthly throughout the treatment phase. In addition, examinations were conducted at 2, 4, 8, and 12 weeks after the last treatment. Fourteen patients received all 12 scheduled treatments, while one patient received only 10 treatments due to complications secondary to pneumonia. RESULTS: Using Paulus 50% criteria, 9 of 15 (60%) patients were improved at the 4th month, and one more fulfilled >20% Paulus criteria (7%) in the 5th month after starting therapy. The study group reported an average of 2.47 adverse effects per treatment, of which the most common were joint pain and swelling and fatigue of short duration (arthritic flare). CONCLUSION: The adverse effects associated with this apheresis based treatment proved to be manageable and of short duration and resolved without sequelae. The results suggest that extracorporeal protein A therapy may have a role in the management of refractory RA, and encouraged the initiation of a larger, blinded, controlled clinical trial.

Modulation of idiotypic and antiidiotypic immunoglobulin G responses in an alloimmune thrombocytopenic patient associated with extracorporeal protein A immunoadsorption.

In the present case study, a patient with Non-Hodgkin. Lymphoma underwent combination chemotherapy resulting in severe pancytopenia requiring transfusion support with blood products. The patient became refractory to random donor platelet transfusions and subsequently received five immunoadsorption treatments. The patient's clinical response to immunoadsorption therapy was assessed by monitoring platelet transfusion recovery and survival. In addition, changes in antibody responses were assessed. Early during the course of immunoadsorption therapy, antiplatelet immunoglobulin G (IgG) alloantibody was detected. There was a decline in antiplatelet IgG alloantibody levels by the last immunoadsorption treatment associated with increases to platelet correct count increments after completion of immunoadsorption therapy. In addition, elevated levels of antiidiotypic IgG antibody detected early during the course of therapy were significantly reduced by the last immunoadsorption treatment. This case study suggests that specific alloimmune idiotypic IgG antibody and corresponding antiidiotypic IgG antibody responses may be modulated in association with extracorporeal immunoadsorption employing protein A/silica columns.

Pharmacological modulation of rat monocytes: in vivo effects on Ia expression and interleukin-1 production.

We have shown that during the developing phase of adjuvant disease (AD) in rats the expression of MHC class II (Ia) antigens on blood monocytes (BM) was enhanced. The results of a study in established AD are reported now. Four agents were tested: indomethacin and diclofenac-sodium (1 mg/kg/day); levamisole and prinomide (10 mg/kg/day), administered orally from day 18-31 after induction of AD. We assessed the following BM parameters: Ia expression, interleukin-1 (sIL-1) production, and membrane bound IL-1 (mIL-1). In AD Ia expression was enhanced, no changes occurred in mIL-1 or sIL-1. Indomethacin treatment reduced sIL-1 production, levamisole Ia expression and mIL-1 activity, prinomide all three parameters measured and diclofenac, though clinically effective, none.

Macrophage function during the development of adjuvant disease.

Using rat peritoneal macrophages and blood monocytes we examined the relationship of developing adjuvant disease (AD) with the expression of class I and II antigens, release of interleukin-1 (IL-1) and production of prostaglandin E2 (PGE2). We observed that class I and II antigens initially decreased; class II remained low throughout, whereas class I returned to normal. PGE2 and IL-1 gradually increased. Treatment in vivo with the NSAID Na-diclofenac lowered PGE2 and IL-1 release and partly reversed the observed reduction of class I and II antigens. Also, exposure of the cells in vitro to lipopolysaccharide increased class I antigen expression.

Appearance of Ia antigens on T lymphocytes stimulated by streptococcal mitogen as an in vitro model of autoimmunity.

Streptococcal mitogen (SM) is an extracellular product of group A streptococci, which is nonspecifically mitogenic for both B and T lymphocytes. The mitogenic activity of SM is resistant to digestion with trypsin, to heating at 100 degrees C for 5 min and to treatment with dithiothreitol. The proliferative response of lymphocytes from patients with a history of rheumatic fever is similar to that of lymphocytes from healthy donors when stimulated with optimal concentrations of SM, but is significantly reduced when low doses of SM are used. T lymphocytes stimulated with SM acquire la antigens and the ability to stimulate allogeneic and autologous lymphocytes in mixed lymphocyte reactions. An involvement of la antigens in these reactions is indicated by the specific block by monoclonal antibodies. T lymphocytes may acquire la antigens following exposure to an appropriate antigen. If this occurs following a streptococcal infection, these in vitro findings suggest that la bearing T cells may play a role in the immunopathological events which can follow a streptococcal infection. The system described may be a useful in vitro model to analyse the immunopathological events which can follow a streptococcal infection and to develop therapeutic approaches to autoimmune conditions.

In vivo and in vitro immunomodulatory ability of streptococcal mitogen: effects on adjuvant disease in the rat; on homograft rejection in the mouse; and on the appearance of Ia antigens on human T lymphocytes.

Streptococcal mitogen (SM) is an extracellular product of group A streptococci, nonspecifically mitogenic for both B and T lymphocytes. The mitogenic activity of SM is resistant to digestion with trypsin, to heating at 100 degrees C for 5 min and to treatment with dithiothrietol. The proliferative response of lymphocytes from patients with a history of rheumatic fever is similar to that of lymphocytes from healthy donors when stimulated with optimal concentrations of SM, but is significantly reduced when low doses of SM are used. Rats were treated with s.c. injections of SM for 21 days at various times from the injection with adjuvant: both primary and secondary reactions in the joints were depressed, more so with pretreatment and early treatment. A similar pattern of response was observed in the survival of A tail skin grafts on the flank of CBA mice: a strain combination with strong H-2 incompatibility. Human T lymphocytes stimulated with SM acquired Ia antigens and the ability to stimulate allogeneic and autologous lymphocytes in mixed lymphocyte reactions. An involvement of Ia antigens in these reactions was indicated by the specific block by monoclonal antibodies to human Ia antigens. T lymphocytes may acquire Ia antigens following exposure to an appropriate antigen. If this occurs following a streptococcal infection, our in vitro findings suggest that Ia bearing T cells may play a role in the immunopathological events which can follow a streptococcal infection. This in vitro system may be a useful model to analyse these immunopathological events and to develop therapeutic approaches in autoimmune conditions. The in vitro findings, together with the observed suppressive effects on the in vivo models described, indicate that SM is a valuable means for study and manipulation of a variety of immune responses.

Inhibitory effect of sera from rheumatoid arthritis patients and enhancing effect of levamisole on total E-rosette levels of lymphoid cells from normal and RA subjects.

We determined the E-rosette levels (E-R) in rheumatoid arthritis patients (RA) and repeatedly tested a selected group with depressed E-R. We also evaluated, in vitro, the inhibitory effect of RA sera on normal E-R and the enhancing effect of levamisole (LV) on normal and RA E-R. Selection criteria and E-R protocol were those of Di Perri (1979). Mononuclear cells (MNC) from 23 normal donors had a mean E-R of 53 +/- 7% (X +/- SD) and this was unchanged after incubation with 32 microM LV. MNC from 31 RA displayed a value of 42 +/- 7% which was lower (p = 0.01) than the normal values and which increased to 47 +/- 9% after LV treatment (p = 0.02). Twenty of these RA did not show enhanced E-R after LV; the remaining 11 RA had E-R of 37 +/- 6% which were restored to 50 +/- 8% after incubation with LV (p = 0.001). We defined this latter group of RA as depressed responders (DR). Four DR were tested repeatedly over a four-month period and consistently remained depressed. Their sera had inhibitory activity on E-R of healthy donors. In vitro treatment of healthy MNC with these RA sera plus 3.2 microns LV abrogated the inhibitory effect. Both the IgG and the IgM fractions of the RA sera manifested this inhibitory effect. We conclude that RA can have depressed E-R which are not transient and can be corrected by in vitro incubation with an immunomodulator. Sera from these RA can inhibit E-R of normal MNC, and LV can abrogate the inhibitory activity of such sera.

Adenosine and adenosine analogues are more toxic to chronic lymphocytic leukemia than to normal lymphocytes.

We compared the effect of adenosine and adenosine analogues on the phytohemagglutinin-induced proliferative response of blood lymphocytes from normal subjects and patients with chronic lymphocytic leukemia. As measured by the inhibition of thymidine or leucine incorporation, adenosine was more toxic to chronic lymphocytic leukemia (CLL) than to normal lymphocytes. This difference was not affected by the removal of adherent cells. The patients' B lymphocytes were more susceptible to adenosine toxicity than normal B lymphocytes. Similar responses were noted in T lymphocytes from both sources. Differential susceptibility was also observed with deoxyadenosine and adenosine analogues, including 5'deoxyadenosine. Uridine rescue from adenosine toxicity was observed for normal and CLL lymphocytes. In the presence of uridine, there was no difference in the residual inhibition of CLL as compared to normal lymphocytes. Intact CLL lymphocytes metabolized 14C-adenosine at a much lower rate than normal lymphocytes. While it appears that the greater toxicity of adenosine to CLL lymphocytes reflects the impaired catabolism of this nucleoside by these cells, evidence is presented that this is not the only mechanism underlying the differential susceptibility. These results may serve as the basis for further pharmacologic investigations of adenosine and adenosine deaminase inhibitors in chronic lymphocytic leukemia.

Immunosuppressive activity of BCG: effects of adjuvant disease, lymphocyte subpopulations, and homing of thoracic duct cells in rats.

Administration of BCG by various dosage schedules suppressed adjuvant disease in rats. BCG administration produced an initial increase, followed by a depression, of the phytohemagglutinin response of purified blood lymphocytes. An increase in absolute and relative numbers of bursa-equivalent (B)-cells followed BCG administration, concurrent with a decrease in the phytohemagglutinin responsiveness. With adjuvant alone, there was a diminution in phytohemagglutinin response and an increase in number of B-cells; the latter occurred immediately after adjuvant injection and also when the generalized disease appeared. When both BCG and adjvant were present, parallel increases of phytohemagglutinin responsiveness and B-cell numbers resulted. The pattern of tissue localization of radioactively labeled thoracic duct cells from normal or BCG-treated donors given to normal, BCG-treated, adjuvant-injected, and BCG-treated + adjuvant-injected syngeneic recipients indicated significantly greater homing to the thymus and decreased localization to the bone marrow when BCG had been given to either donors or recipients. When labeled thymus cells were used, only the decreased bone marrow localization was noted. These observations suggest that the suppressive effect of BCG may be mediated through modification of the lymphocyte recirculation pattern, possibly resulting from alterations in lymphocyte recognition sites.

Cyclic adenosine 3':5'-monophosphate phosphodiesterase activity in normal and chronic lymphocytic leukemia lymphocytes.

The specific activity of cyclic adenosine 3':5'-monophosphate phosphodiesterase was measured in lymphocytes isolated from the blood of normal subjects, from patients with chronic lymphocytic leukemia, and from tonsil tissue. The mean specific activity of cyclic adenosine 3':5'-monophosphate phosphodiesterase in the lymphocytes from patients with untreated chronic lymphocytic leukemia was lower than that in lymphocytes from the blood of normal subjects or from tonsils. Cyclic adenosine 3':5'-monophosphate phosphodiesterase levels did not correlate with differences in B- and T-cell lymphocyte subpopulations or with peripheral blood lymphocyte counts.

Adenosine deaminase activity in chronic lymphocytic leukemia. Relationship to B- and T-cell subpopulations.

The level, phenotypes, and isozyme distribution of adenosine deaminase (ADA) were determined in lymphocytes from patients with chronic lymphocytic leukemia (CLL). The ADA level in lymphocytes from patients with untreated CLL was consistently lower than in lymphocytes from normal subjects. No significant differences were found in the phenotype or isozyme distribution. In untreated patients, the ADA level was inversely correlated with the lymphocyte count and the percentage of bursa-equivalent (B) cells. After therapy, a diminution in the lymphocyte count was associated with an increase of ADA activity towards normal levels. The ADA levels were slightly higher in the thymus-derived (T) than in the B lymphocytes from normal subjects. The B cells had lower activity than T cells in patients with CLL. They also had a lower activity than the B cells from normal subjects. The ADA level was 2.3-fold higher in T cells from patients with CLL than in normal T cells. The decrease in ADA levels is an anomaly that is reversible and appears to be a reflection of the proliferation of abnormal B cells in this disorder.