Zusammenfassung
Zahlreiche rheumatologische Erkrankungen werden entweder durch spezifische, bekannte Proteine, wie z. B. Antikörper, verursacht oder durch eine Vielzahl von Mediatoren vermittelt. Sowohl die spezifischen Interventionen mit Biologika als auch die unspezifische Immunsuppression benötigen häufig längere Zeit bis zum Wirkungseintritt. Aus diesem Grund werden bei einigen besonders schwer verlaufenden rheumatologischen Erkrankungen oder bei Unverträglichkeit bzw. zu hohem Risiko einer immunsuppressiven Medikation extrakorporale Verfahren eingesetzt. Mithilfe der Plasmapherese können pathologische Substanzen wie Autoantikörper und Immunkomplexe, aber auch Zytokine entfernt werden. Das entfernte Plasma muss hierbei durch Blutprodukte (Humanalbumin oder Frischplasma) ersetzt werden. Frischplasma kommt immer dann zum Einsatz, wenn fehlende Substanzen im Plasma von Patienten substituiert werden sollen, wie z. B. ADAMTS-13 bei thrombotisch-thrombozytopenischer Purpura. Wird das separierte Plasma erneut mittels eines Sekundärfilters („cut-off“ ~700 kD) abermals filtriert, können auf diese Weise LDL-Cholesterin oder IgM eliminiert werden. Diesen Vorgang bezeichnet man als Kaskadenfiltration, die z. B. bei Morbus Waldenström eingesetzt wird. Eine spezifischere Form der Entfernung von Antikörpern stellt die Immunadsorption dar, bei der eine möglichst selektive Entfernung von Antikörpern mittels eines Adsorbers erfolgt. Für dieses Verfahren sind keine Blutprodukte erforderlich. Die nachfolgende Übersicht vermittelt die Grundlagen beider Verfahren, ihre Vor- und Nachteile und fasst darüber hinaus den Kenntnisstand bezüglich der Einsatzgebiete beider Verfahren im Bereich rheumatologischer Erkrankungen zusammen.
Abstract
Many rheumatological diseases are either caused by specific known proteins, such as antibodies or mediated by a plethora of cytokines. Both the unspecific immunosuppressive therapy and the specific action of biologics usually require time to be effective; therefore, extracorporeal forms of treatment are increasingly being employed in severe forms of rheumatological diseases as well as in patients who cannot tolerate pharmacological treatment or where the risk of pharmacological treatment may outweigh the potential benefits. Therapeutic plasma exchange (TPE) removes not only pathogenic substances, such as autoantibodies, lipoproteins and circulating immune complexes from the plasma but also cytokines. The removed plasma that is discarded has to be substituted by blood products, e.g. human albumin or fresh frozen plasma. Fresh frozen plasma is always used when missing plasma components must be replenished, such as ADAMTS-13 in thrombotic thrombocytopenic purpura (TTP). The separated plasma can be further processed by pumping into a hollow fiber filter (cut-off of ~700 kD) and in this way low-density lipoprotein cholesterol and IgM can be eliminated. This treatment mode, called cascade filtration is used to treat diseases, such as Waldenström’s macroglobulinemia and cryoglobulinemia. A specific way to remove antibodies is by immunoadsorption in which the antibodies are specifically removed by an adsorber. For this procedure there is no need to substitute blood products. This review article describes the principles of the two different treatment methods, the advantages and disadvantages and also summarizes the current evidence for their use in rheumatological diseases.
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J.T. Kielstein erhielt Forschungsförderung und Vortragshonorare von Fresenius Medical Care, Diamed und Terumo BCT. M. Boser gibt an, dass kein Interessenkonflikt besteht.
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R.E. Schmidt, Hannover
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Boser, M., Kielstein, J.T. Rolle von Plasmapherese und Immunadsorption in der Rescue-Therapie rheumatologischer Erkrankungen. Z Rheumatol 75, 964–972 (2016). https://doi.org/10.1007/s00393-016-0219-7
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DOI: https://doi.org/10.1007/s00393-016-0219-7