Safety and effectiveness of apheresis in the treatment of infectious diseases: a systematic review
The Journal of infection. 2019
OBJECTIVES Apheresis has been used as adjunctive treatment of severe falciparum malaria, loiasis and babesiosis. This systematic review aimed to investigate the safety and efficacy of apheresis in the treatment of these conditions. METHODS MEDLINE, PUBMED, EMBASE and CINAHL databases were searched to identify studies published between January 1969 and March 2018 involving patients treated using apheresis for severe falciparum malaria, loiasis or babesiosis. Data extracted included details about the apheresis intervention, populations, study methods and outcomes relating to efficacy and safety. RESULTS A total of 67 publications met the inclusion criteria and were included in the data synthesis, 36 for malaria (70 cases), 17 for babesiosis (22 cases) and 14 for loiasis (34 cases). Publications were case reports, case series, and cohort studies; there were no randomised controlled trials identified. Potential publication bias was considered to be high. CONCLUSIONS Systematic review of the literature suggests that apheresis may be a useful adjunct in the treatment of patients hospitalised for babesiosis, and prior to chemotherapy in loiasis with microfilarial count >8000 parasites/mL. Data does not support the use of apheresis in patients with severe falciparum malaria.
Role of Plasmapheresis and Extracorporeal Membrane Oxygenation in the Treatment of Leptospirosis Complicated with Pulmonary Hemorrhages
Journal of tropical medicine. 2018;2018:4520185
Introduction: Leptospirosis is an emerging infectious disease associated with multiorgan involvement and significant morbidity and mortality. Although pulmonary hemorrhage due to leptospirosis has a high fatality, specific treatment options are limited and their efficacy is not adequately proven. We opted to find out the current evidence on plasmapheresis and extracorporeal membrane oxygenation (ECMO) in pulmonary hemorrhages due to leptospirosis. Methods: The first search was conducted in PubMed, OVID, Google Scholar, and Cochrane clinical trial registry using keywords "leptospirosis" OR "Leptospira" OR "Weil's disease" AND "plasmapheresis" OR "plasma exchange" AND "pulmonary hemorrhage" OR "alveolar hemorrhage" OR "lung hemorrhage" and the second search was done using keyword "leptospirosis" OR "Leptospira" OR "Weil's disease" AND "ECMO" OR "Extracorporeal membrane oxygenation." The searches were not limited by study design or the date of publication. Only articles written in English were reviewed. Although we intended to include only clinical trials, it was decided later to include other information such as case reports and case series which addressed these treatment modalities. Two authors selected articles independently in a blinded manner using a set of inclusion and exclusion criteria and discrepancies were solved after discussions. Results: The information found was very limited. This included one clinical trial which showed a significant survival benefit with plasmapheresis but the study design had many limitations. Two case reports described the benefit of plasmapheresis in severe leptospirosis with pulmonary hemorrhages. There were eight case reports where ECMO was performed and out of all only one patient has died. One retrospective study on patients with severe leptospirosis mentioned that four out of five patients with pulmonary hemorrhages survived after being treated with ECMO. Conclusions: Current evidence is insufficient to recommend the routine use of plasmapheresis or ECMO for patients presenting with pulmonary hemorrhages due to leptospirosis. ECMO may be a promising mode of treatment in acute respiratory failure in leptospirosis related pulmonary hemorrhages. These treatment modalities, however, can be applied based on the availability of resources and expertise at the discretion of the clinician in charge, considering patient related factors such as cardiovascular stability and derangement of coagulation profile. Clinical trials conducted adhering to standard procedures are urgently required to establish the efficacy of these treatment modalities.
Favorable outcome of ex-vivo purging of monocytes after the reintroduction of treatment after interruption in patients infected with multidrug resistant HIV-1
Journal of Medical Virology. 2007;79((11):):1640-9.
In multidrug resistant patients treatment interruptions allow the selection of archived wild-type drug-susceptible viruses that compete for the less fit drug-resistant strains. However, the selection of viruses with increased replicative capacity is often followed by a loss of CD4+ T cells. In addition, drug resistant variants later re-emerge limiting the overall clinical benefit of treatment interruption. Blood monocytes are a key component of the HIV reservoir and can be partially removed by a system for purging of myeloid cells (MYP). This study tested the safety and efficacy of MYP on multidrug resistant patients who underwent treatment interruption. Twelve patients were randomized to receive or not six cycles of MYP during treatment interruption. An optimized antiretroviral regimen was reintroduced after the reappearance of a drug susceptible genotype. Following therapy reintroduction, a long lasting increase in CD4+ T cell counts was observed only in the treatment interruption + MYP patients but not in the control patients. Five/six treatment interruption + MYP patients never experienced virological rebound during a median follow up period of 98 weeks. In contrast, 4/6 patients who did not receive MYP never reached complete viral suppression and had a virological rebound after a median of 16. 5 weeks after treatment reintroduction. The difference between the two groups in the time to virological rebound was statistically significant (P = 0. 021). A consistent decrease of HIV DNA load in CD14+ purified cells was observed only in treatment interruption + MYP patients. These data suggest that MYP can improve the immunological and virological response to treatment interruption.
Granulocyte/monocyte apheresis induces sustained increases in CD4 T cells in HIV-1 infected patients with poor CD4 T cell restoration after suppression of viral replication by HAART
Journal of Biological Regulators & Homeostatic Agents. 2002;16((1):):58-63.
Current antiretroviral regimens (HAART) are generally effective in reducing viral replication to undetectable levels and inducing a raise in CD4 T cells. However, in approximately 5 to 15% of patients suppression of viral replication is not followed by an increase in CD4 T cells. Such patients may be at increased risk for opportunistic infections. Here we report the results from a phase II open label randomised trial on 30 patients classified as poor responders to HAART who were either subjected to eight consecutive cycles of selective monocyte apheresis or maintained under HAART alone. The results show that monocyte apheresis results in increased CD4 T cell counts which are maintained for at least 31 weeks after last apheresis. This effect was observed only on patients with complete suppression of viral replication. Other effects of monocyte apheresis included a strong reduction of TNF-alpha production in patients with high baseline levels of this cytokine and activation of resting T cells during the apheresis cycles. In two patients with high cellular HIV DNA load apheresis was followed by a 98% reduction, suggesting purging of infected cells. There was no evidence of increased viral replication during or after the apheresis cycles. The data show that monocyte apheresis is safe, well tolerated and may be indicated in patients who respond poorly to HAART.
Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis
Clinical Infectious Diseases. 2002;34((9):):1192-8.
The efficacy of exchange transfusion as an adjunct treatment for severe falciparum malaria is controversial. No sufficiently powered, randomized, controlled study has been reported. We analyzed 8 studies that compared survival rates associated with adjunct exchange transfusion with those associated with antimalarial chemotherapy alone. Exchange transfusion was not associated with a higher survival rate than was antimalarial chemotherapy alone (odds ratio (OR), 1.2; 95% confidence interval (CI), 0.7-2.1). However, patients who received transfusions had higher levels of parasitemia and more-severe malaria. Sensitivity analysis found that survival rates were higher among patients with partial immunity to malaria (OR, 0.5; 95% CI, 0.2-1.2) than they were among patients with no immunity (OR, 2.1; 95% CI, 0.9-4.8; P=.007). Exchange transfusion does not appear to increase the survival rate; however, there were significant problems with the comparability of treatment groups in the studies reviewed, and a randomized controlled trial is necessary to determine whether exchange transfusion is beneficial.
Treatment of severe malaria by exchange transfusion
New England Journal of Medicine. 1990;322((1):):58-9.