Suzuki, Yasuo; Yamada, Akihiro; Aoki, Hiroshi; Osamura, Aisaku; Nakamura, Kentaro; Yoshimatsu, Yasushi; Hosoe, Nobuo; Takada, Nobuo; Tsuda, Yukio; Shirai, Koji (2008). W1254 The Decreased TLR2 Expression and Elevated IL-8 Production On Peripheral Leukocytes in Patients with Active Ulcerative Colitis: the Modulation of the Leukocyte Sensitivity to Pgn By Granulocyte and Monocyte Apheresis. Gastroenterology, 134(4), A-665–. doi:10.1016/S0016-5085(08)63105-4
Tag: gma
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W1254 The Decreased TLR2 Expression and Elevated IL-8 Production On Peripheral Leukocytes in Patients with Active Ulcerative Colitis: the Modulation of the Leukocyte Sensitivity to Pgn By Granulocyte and Monocyte Apheresis
BACKGROUND & AIM: Mucosal lesions of active ulcerative colitis (UC) are characterized by acute inflammatory cell (polymorphonuclear granulocyte, PMN) infiltrate and ulceration. Granulocyte and monocyte apheresis (GMA) using a column device, Adacolumn, selectively adsorbs and removes leukocytes from the peripheral blood, and has been reported to be effective in patients with active UC. The aim of this study was to investigate the expression of toll like receptor 2 (TLR2) on PMNs and monocytes in patients with active UC as compared to the level in healthy subjects and see the impact of GMA on TLR2. METHODS: Fortyeight patients with active UC, Clinical Activity Index (CAI, Lichtiger index) ≥5, were included in this study. Patients received several GMA sessions (maximum 10 sessions), and CAI ≤ 3 was considered remission. Blood samples were obtained from patients at each GMA session and also from healthy subjects (n=14), after obtaining informed consent. The expression of TLR2 was investigated by flowcytometry. In several samples, IL-8 production by cultured blood upon stimulation with peptidoglycan (PGN, a ligand for TLR2) was measured (n=21). RESULTS: An average of CAI at the entry was 11.0 (n=48), and remission rate by GMA was 56.3%(27/48). At the baseline, the expression of TLR2 on PMN of patients with active UC was significantly less than the level in healthy subjects (p<0.001). Further, the improvement in CAI was accompanied by a trend towards normalization of TLR2 on PMN (up-regulation, p<0.05) together with a significant fall (P<0.01) of plasma IL-8 level. However, as for the patients with still active symptoms (CAI>5) in course of GMA therapy, the decreased TLR2 on PMN and the elevated release of IL-8 from PGN-stimulated leukocytes were kept on. By exposing blood to the column carriers In Vitro, TLR2 expression on the cell surface of PMN was decreased, but increased within the cellular of PMN. Similarly, in the blood on column outflow of GMA, the TLR2 expression on PMN and IL-8 production by PGN-stimulation were significantly decreased (TLR2:P<0.001, IL-8:P<0.001), indicating that leukocyte sensitivity to PGN is weakened by GMA column. CONCLUSION: The expression of TLR2 on PMN in patients with active UC is significantly decreased compared with remission status or healthy subjects. In connection with the decreased TLR2 expression, the IL-8 production by PGN-stimulated leukocytes is elevated in patients with active UC. These changes seem to reflect PMN activation based on UC disease activity. GMA or exposure of blood to GMA carriers is associated with down-modulation of the TLR2 expression on PMN and also leukocyte sensitivity to PGN
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In patients with ulcerative colitis, adsorptive depletion of granulocytes and monocytes impacts mucosal level of neutrophils and clinically is most effective in steroid naïve patients
T Tanaka 1, H Okanobu, S Yoshimi, E Murakami, A Kogame, H Imagawa, Y Numata, Y Kuga, T Moriya, T Ohya, G Kajiyama
Background: The aetiology of ulcerative colitis is inadequately understood, and drug therapy has been empirical rather than based on sound understanding of disease aetiology. This has been a major factor for refractoriness and adverse drug effects as additional complications. However, ulcerative colitis by its very nature is exacerbated and perpetuated by inflammatory cytokines, which are released by peripheral granulocytes and monocytes as well. Additionally, active ulcerative colitis is often associated with elevated peripheral granulocytes and monocytes with activation behaviour and are found in vast numbers within the colonic mucosa. Hence, from the clinicopathologic viewpoint, granulocytes and monocytes are appropriate targets for therapy in ulcerative colitis. Based on this thinking, an Adacolumn has been developed for depleting excess granulocytes and monocytes by adsorption. Methods: By colonoscopy, biopsy and histology, we investigated the impact of granulocyte and monocyte adsorption (GMA) on the mucosal level of granulocytes and monocytes in patients with active ulcerative colitis. Forty-five patients (26 steroid naïve and 19 steroid-dependent), mean age 44.7 yr, were included. Twenty patients had total colitis and 25 had left-sided colitis. Each patient was given up to 11 GMA sessions over 12 weeks. No patient received additional medications within 4 weeks (steroid) to 8 weeks (other immunosuppressants) prior to entry or during the GMA course. Colonoscopy together with biopsy was done at entry and within 2 weeks after the last GMA session. Results: At entry, the mean clinical activity index was 12.6; range 10-16. A total of 400 colonic biopsies were examined, which revealed massive infiltration of the colonic mucosa by granulocytes, and GMA was associated with striking reduction of granulocytes in the mucosa. At week 12, 33 of 45 patients (73.3%, P<0.01) had achieved clinical remission (the mean clinical activity index <or= 4). Colonoscopy revealed that most non-responders had deep colonic ulcers and extensive loss of the mucosal tissue. The response rate in steroid naïve subgroup was 22 of 26 patients (84.6%, P<0.005) and in steroid-dependent was 11 of 19 (57.9%, P<0.05 and P=0.02154 for steroid naïve vs. steroid-dependent). Patients who achieved remission could continue with their salicylates. On average, remission was sustained for 7.8 months in all 33 responders. Conclusions: This is the first report showing a striking difference in clinical response to GMA between steroid naïve and steroid-dependent patients. Further, patients with deep colonic ulcers together with extensive loss of the mucosal tissue are not like to respond to GMA.
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Efficacy of granulocyte and monocyte adsorption apheresis for pustular psoriasis
Granulocyte and monocyte adsorption apheresis (GCAP) has recently shown remarkable effects on ulcerative colitis, which is characterized by inflammation and neutrophil infiltration. Pustular psoriasis often shows histological findings of neutrophilic pustules in the epidermis, and in Japan is usually treated with etretinate or immunosuppressive agents. However, there are some resistant cases to these therapies. We performed GCAP on one patient with generalized pustular psoriasis (patient 1) and on one patient with acrodermatitis continua, a subtype of pustular psoriasis limited to acral lesions (patient 2). Patient 1, a 44-year-old woman suffering from alcoholic liver cirrhosis and osteoporosis as a result of the liver cirrhosis, received two GCAP sessions because cyclosporine was ineffective. Patient 2, a 66-year-old man with hypertension who had suffered from a brain infarction 4 years before, had five GCAP sessions because etretinate was ineffective. GCAP remarkably improved the skin lesions in both patients. No adverse effects were observed either during or after treatment. From these findings, GCAP could be an effective therapy for refractory cases of pustular psoriasis.
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Reduction of Dendritic Cells by Granulocyte and Monocyte Adsorption Apheresis in Patients with Ulcerative Colitis
The influence of the granulocyte/monocyte apheresis (GMCAP) on cell populations participating in mechanisms of tolerance, e.g. dendritic cells (DCs), is still not very clear. In a first step, we aimed to investigate changes in the DC population of patients suffering from ulcerative colitis (UC) (n = 13) compared to healthy subjects (n = 9). In a second step, we studied the changes in peripheral DCs in a small group of patients with active UC before and after Adacolumn apheresis (n = 7). For this purpose, plasmacytoid and myeloid DCs and their maturation markers CD40, CD80, and CD86 were measured using four-color flow cytometry in the peripheral blood. After apheresis, and in acute flare-ups, we identified a significantly lower number of lymphocytes, plasmacytoid, and myeloid DCs. In conclusion, the additional removal of peripheral DCs by GMCAP, which otherwise would contribute to the inflammatory process in the gut, may lead to a higher tolerogeneic status towards luminal antigens.
dendritic cells / gma / leukocyte / MOA / plasmacytoid / T-lymphocytes / tolerogenic / ulcerative colitis /
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A Case Report of Steroid and Immunosuppressant-resistant Pyoderma Gangrenosum Successfully Treated by Granulocytapheresis
Abstract: Granulocytapheresis (GCAP) therapy is a newly developed therapeutic modality for inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. Pyoderma gangrenosum (PG) is a chronic inflammatory skin disease characterized by the appearance of erythematous macules and plaques with pustules or nodules that rapidly progress to ragged, undermined multiple ulcers. We attempted GCAP therapy in a patient with PG resistant to prednisolone and various other immunosuppressants. GCAP therapy was initiated at three- to four-day intervals and a good response from all skin lesions, with eventual total epithelialization, was observed after 10 sessions of this therapy. Furthermore, circulating levels of inflammatory cytokines such as interleukin-8 (IL-8) and granulocyte colony stimulating factor (G-CSF) also decreased after the GCAP therapy. Our results suggest that GCAP is a safe and useful tool for the treatment of intractable PG, and that IL-8 and G-CSF are likely to be involved in the pathogenesis of PG.
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Current pharmacologic treatment paradigms for inflammatory bowel disease and the potential role of granulocyte/monocyte apheresis
David Schwartz 1, John R Ferguson, Curr Med Res Opin . 2007 Nov;23(11):2715-28.
Background: A broad range of pharmacologic therapies are available to treat active inflammatory bowel disease (IBD), including 5-aminosalicylate preparations, corticosteroids, and immunosuppressants (e.g., azathio prine/6-mercaptopurine [AZA/6-MP] or methotrexate). Although these therapies are effective, up to 60% of patients are refractory or intolerant. Biologic therapies, such as the anti-TNF agent infliximab, offer promise but are not without controversy; despite many positive reports, steroid-refractory patients are less likely than other individuals to respond to infliximab. Effective, long-term therapies that do not add to the adverse-effects burden in patients with IBD are needed. Of these, granulocyte/monocyte apheresis (GMA) is one promising approach.
Scope: PubMed and relevant congresses databases were searched using the terms ‘granulocyte/monocyte apheresis,’ ‘GMA,’ ‘leukocytapheresis,’ ‘Adacolumn,’ and ‘Cellsorba.’ These studies were further selected to include only those focusing on IBD. A time frame of 2000-2006 was used.
Findings: Data from open-label trials show that patients with moderate-to-severe IBD refractory to conventional pharmacologic treatment achieved clinical response and/or remission after treatment with GMA. Furthermore, recent small open-label trials of GMA show increased rates of induction and maintenance of response/remission in steroid-naïve IBD patients.
Conclusions: The remission rates seen in these open-label clinical trials of GMA are consistent with those of currently available pharmacologic therapies for IBD. However, the majority of these trials enrolled only small numbers of patients, were largely open-label, and were of limited duration. These data must be confirmed in well-controlled, large-scale clinical trials
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Leucocyte apheresis in the treatment of paediatric ulcerative colitis
Tarja Ruuska, Marja-Leena Lähdeaho, Yelda Sutas, Merja Ashorn, Juhani Grönlund Scand J Gastroenterol 2007 Nov; 42(11):1390-1. doi: 10.1080/00365520701231116.
Recent studies show corticosteroid dependency in 45% of paediatric ulcerative colitis (UC) patients despite using other medicaments, including immunomodulators This patient group is problematic as corticosteroids have numerous side effects when used long term. New biological approaches have proved effective in the treatment of inflammatory bowel disease (IBD), but as the side effects can be severe, especially in young patients, their use is restricted in UC.
In UC, circulating activated granulocytes and macrophages/monocytes are increased and can infiltrate the bowel and cause tissue injury by producing inflammatory cytokines, being thus involved in the initiation and perpetuation of an inflammatory disorder. Periodic removal of activated granulocytes and monocytes/ macrophages with selective leucocyte apheresis (Adacolumn; JIMRO, Japan) is expected to reduce leucocyte-dependent tissue injury. Preliminary reports show promising results in the treatment of IBD, in children with corticosteroid-dependent or -resistant UC.
We design a pilot study where 11 children (7 corticosteroid-dependent, 3 corticosteroid-resistant and 1 refusing corticosteroids) were treated with apheresis and their data analysed. Treatment was given once a week, a total of 5-9 sessions. 8 out of the remaining 11 patients responded well to the treatment. Corticosteroids could be tapered-off either totally or to minimal doses in all cases. Treatment was well tolerated.
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Granulocyte Apheresis in Inflammatory Bowel Disease: Possible Mechanisms of Effect
B.J. Rembacken,H.E. Newbould,S.J. Richards,S.A. Misbah,M.E. Dixon,D.M. Chalmers,A.T.R. Axon THERAP APHERE DIAL (2007) 2 (2) 93-96 https://doi.org/10.1111/j.1744-9987.1998.tb00082.x
We have studied the effects of granulocyte apheresis in 18 patients with ulcerative colitis and 6 with Crohn’s disease who had failed to respond to conventional therapy. Patients were treated with weekly apheresis using a granulocyte removal column. We found a mean reduction in circulating granulocytes of 1.29 × 109 cells/L with no significant alterations in red blood cell monocyte, total lymphocyte, absolute T-helper, or T-cytotoxic lymphocyte counts. There were no significant changes in complement levels or immunoglobulin subclasses. There was a signifycant increase in granulocyte adhesion and a reduction in L-selectin expression. The removal of granulocytes is unlikely to explain the effect of granulocytapheresis. The markedly increased expression of αm integrin/Mac-1 and low L-selectin expression alter the capability of granulocytes to migrate to sites of inflammation and may be responsible for the improvement observed in patients treated with granulocyte apheresis.
https://pubmed.ncbi.nlm.nih.gov/10225706/
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Demonstration of low-regulatory CD25High+CD4+ and high-pro-inflammatory CD28-CD4+ T-Cell subsets in patients with ulcerative colitis: modified by selective granulocyte and monocyte adsorption apheresis
Yoko Yokoyama 1, Ken Fukunaga, Yoshihiro Fukuda, Katsuyuki Tozawa, Koji Kamikozuru, Kunio Ohnishi, Takeshi Kusaka, Tadashi Kosaka, Nobuyuki Hida, Yoshio Ohda, Hiroto Miwa, Takayuki Matsumoto Dig Dis Sci 2007 Oct;52(10):2725-31. doi: 10.1007/s10620-006-9560-z. Epub 2007 Apr 3.
Low-CD25(High+)CD4(+), a subset of regulatory CD25(+)CD4(+) T cells and high-inflammatory CD28(-)CD4(+) T cells can exacerbate ulcerative colitis (UC). This study sought to investigate the frequency of CD25(High+)CD4(+) and CD28(-)CD4(+) T cells in patients with UC and the changes in these cells during Adacolumn granulocyte and monocyte adsorption apheresis (GMA). Subjects were 12 patients with active UC, 11 with quiescent UC, and 14 healthy volunteers (HVs). The mean clinical activity index was 15.7 +/- 2.2 in active UC and 4.5 +/- 1.1 in quiescent UC. Peripheral blood samples were stained with CD4, CD25, and CD28 antibodies for flow cytometry. Patients with active UC received GMA and blood samples were examined before and after the first GMA session. Patients with active UC (P < 0.04) or quiescent UC (P < 0.02) had a higher percentage of CD28(-)D4(+)T cells compared with HVs, while the percentage of CD28(+)CD4(+) T cells was lower in both UC groups compared with HVs (P = 0.03 and P < 0.02). Patients with active UC had a lower percentage of CD25(High+)CD4(+)T cells compared with quiescent UC patients (P < 0.001). A significant increase in CD25(High+)CD4(+) T cells was associated with GMA (P < 0.03). Low CD25(High+)CD4(+) and high CD28(-)CD4(+) are prominent features in UC. The increase in CD25(High+)CD4(+) T cells induced by GMA should contribute to improved immune function. Additional studies are warranted, since a low frequency of CD25(High+)CD4(+) (-) and a high frequency of CD28(-)CD4(+) (-) expressing T cells might be a predictor of clinical response to GMA.
active / CD25highCD4+ Tcell / CD28-CD4+ Tcell / CD4+ / gma / MOA / quiescent / T-lymphocytes / Treg / ulcerative colitis /
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The logics of leukocytapheresis as a natural biological therapy for inflammatory bowel disease
Takanori Kanai 1, Toshifumi Hibi, Mamoru Watanabe, Expert Opin Biol Ther. 2006 May;6(5):453-66.
Ulcerative colitis (UC) and Crohn’s disease (CD) are debilitating idiopathic inflammatory bowel diseases (IBDs) with symptoms that impair ability to function and quality of life. The aetiology of IBD is inadequately understood and, therefore, drug therapy has been empirical instead of based on sound understanding of the disease mechanisms. This has been a major factor for poor drug efficacy and treatment-related side effects that often add to disease complications. The development of biologicals, notably infliximab, to block TNF-alpha reflects some progress, but there is major concern about their side effects and lack of long-term safety and efficacy profiles. However, IBD by its very nature is exacerbated and perpetuated by inflammatory cytokines, including TNF-alpha, IL-6 and IL-12, for which activated peripheral blood lymphocytes, monocytes/macrophages and granulocytes are major sources. Hence, activated leukocytes should be appropriate targets of therapy. At present, three strategies are available for removing excess and activated leukocytes by leukocytapheresis: centrifugation, Adacolumn and Cellsorba. Centrifugation can deplete lymphocytes or total leukocytes, whereas Adacolumn selectively adsorbs granulocytes and monocytes together with a smaller fraction of lymphocytes (FcgammaR- and complement receptor-bearing leukocytes), and Cellsorba non-selectively removes all three major leukocyte populations. Efficacy has ranged from ‘none’ to an impressive 93% together with excellent safety profiles and downmodulation of inflammation factors. Furthermore, leukocytapheresis has shown strong drug-sparing effects and reduced the number of patients requiring colectomy or exposure to unsafe immunosuppressants, such as cyclosporin A. Leukocytapheresis removes from the body cells that contribute to IBD and, therefore, unlike drugs, it is not expected to induce dependency or refractoriness.
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