Impact of COVID-19 pandemic in the activity of a Therapeutic Apheresis unit in Italy.

INTRODUCTION: The recent Coronavirus Disease 2019 (COVID-19) outbreak has led to profound and rapid changes in the Italian and Veneto Region Healthcare System. This context also includes the quick reorganization which the Apheresis Unit (AU) of the Padova University Hospital, i.e. the Regional Reference Center for Therapeutic Apheresis (TA), had to face. MATERIAL AND METHODS: The study retrospectively evaluated the TA activity (procedures performed, patients treated and consultations) during the COVID-19 pandemic, from March to April 2020, comparing the activity in the same time period in 2018 and 2019. RESULTS: In the period analyzed, a significant reduction in both the total number of procedures performed and of patients treated, respectively by 17 % and 16 % for the procedures and by 19 % and 20 % for patients treated compared to the same period of 2018 and 2019, respectively, was observed. A concomitant reduction in requests for TA consultation for new patients (both outpatients and inpatients) was observed, equal to 32 % and 21 % compared to 2018 and 2019, respectively. CONCLUSION: Many reasons determined the observed reduction in the TA activity during the recent COVID-19 outbreak. The AU itself was quickly reorganized in terms of location and supplies to allow for the appropriate COVID-19 patients care. Many non urgent cases, after multidisciplinary discussion between Clinicians and Apheresis Specialists, were deferred, maintaining close phone and e-mail contact with patients.

Apheresis treatment of cryoglobulinemic vasculitis: A multicentre cohort study of 159 patients.

OBJECTIVE: To assess the effectiveness of apheresis therapy (AT) in treating the clinical manifestations of patients with complicated cryoglobulinemic vasculitis (CV). METHODS: A retrospective cohort study of 159 CV patients attending 22 Italian Centers who underwent at least one AT session between 2005 and 2015. The response to AT was evaluated on the basis of a defined grading system. RESULTS: Peripheral neuropathy was the most frequent clinical condition leading to AT. Therapeutic plasma exchange was used in 70.4% of cases. The outcome of AT was rated very good in 19 cases, good in 64, partial/transient in 40, and absent/not assessable in 36. Life-threatening CV-related emergencies and renal impairment independently correlated with failure to respond to AT. The independent variables associated with an increased risk of death were age at the time of the first AT session, multi-organ life-threatening CV, the presence of renal impairment and failure to respond to AT. The time-dependent probability of surviving until CV-related death in the second year was 84%, with an AHR in patients with absent/not assessable response to AT of 11.25. CONCLUSION: In this study AT is confirmed to be a safe procedure in patients with CV. Early AT should be considered in patients with severe CV, especially in cases with impending renal involvement, in order to prevent irreversible kidney damage. Although its efficacy in patients with multi-organ failure is limited, AT is the only treatment that can rapidly remove circulating cryoglobulins, and should be considered an emergency treatment.

A combination therapy to treat second-degree anti-Ro/La-related congenital heart block: a strategy to avoid stable third-degree heart block?

While mainly based on the use of fluorinated steroids, there is no standard management of anti-Ro/La-related congenital heart block (CHB). This is a report concerning two consecutive cases of anti-Ro/La-related second-degree block treated with betamethasone (4 mg/day), weekly plasmapheresis, and intravenous immunoglobulins (IVIGs; 1 g/kg) administered every 15 days, a therapy that was begun shortly after CHB was detected and continued until delivery. The newborns were also treated with IVIG (1 g/kg) soon after birth and continued fortnightly until the anti-Ro/La antibody levels became undetectable. In both cases second-degree AV block reverted to a stable sinus rhythm with a first-degree atrioventricular (AV) block. Moreover, there was no recurrence of CHB when therapy was suspended, as confirmed by a 29 month and an eight month follow-up, respectively.

Genetic control of the CD4/CD8 T-cell ratio in humans.

We studied the genetic pattern of inheritance of the ratio between circulating CD4+ and CD8+ T lymphocytes in a population of healthy donors. The distribution of the CD4/CD8 ratio in males and females was significantly different and was significantly affected by age. In 46 randomly selected families, the parental CD4/CD8 ratio significantly influenced the ratio in offspring. Complex segregation analysis of the data rejected the non-genetic hypothesis; among the genetic models tested, a major recessive gene with a polygenic component and random environmental effects was the most parsimonious model. These findings indicate that the ratio of CD4+ and CD8+ T cells is genetically controlled in humans.

The Italian SIdEM registry for apheresis: an overview of the 2005 statistics.

Data collection on apheresis activities in Italy throughout 2005 including techniques, types of blood cell separators, clinical indications and adverse effects was performed by means of a standardized questionnaire. These data provided by 83 Apheresis Units from 16 Italian regions, albeit rough, are sufficiently informative, mainly in comparison with previous surveys on these statistics (1997 and 2000). In 2005 a total number of 204,746 apheresis procedures were carried out, with a clear-cut prevalence of apheresis production (87.7%), performed by 66 out of 83 Apheresis Units (79.5). Lombardy, Veneto and Tuscany were the most active regions for therapeutic apheresis (51.1% of the total national procedures). An increasing number in extracorporeal photochemotherapy as compared to the 2000 national survey (3,386 vs. 704 procedures) is the most striking observation to emerge from the 2005 data collection on therapeutic apheresis in Italy. Adverse effects, predominantly mild ones (i.e., paresthesia due to citrate-induced hypocalcemia), occurred in 0.12% of apheresis production and 6.04 of therapeutic sessions, particularly in the course of peripheral blood stem cell collection (20.79%), as already reported in the 2000 national survey.

Frequency of a mutated CCR-5 allele (delta32) among Italian healthy donors and individuals at risk of parenteral HIV infection.

The aim of this study was to assess the frequency of a truncated allele of the CCR-5 gene (delta32) in Italy, and address its possible role in parenteral HIV transmission, as well as its influence in HIV-associated disease progression. In 371 unrelated seronegative healthy blood donors the delta32 allele frequency was 0.047; this figure was significantly different from those reported in northern America and northern Europe populations. However, delta32 allele frequency in healthy individuals did not differ significantly from that found in 54 seronegative drug users (0.065), 98 seronegative hemophiliacs (0.051), and 81 seropositive hemophiliacs (0.049). Although in seropositive hemophiliacs the wt/delta32 heterozygous genotype was associated with a trend to a slower decline in CD4+ cell counts, its presence did not seem to influence disease progression, as comparable delta32 allele frequency frequencies were found among progressing (0.042) and nonprogressing (0.111) patients. These data do not seem to support a protective role of the delta32 allele in preventing HIV infection through the parenteral route, or in influencing the natural history of the disease in this particular risk category, although the delta32 heterozygous state was associated with lower plasma viremia levels. On the other hand, the finding of non-syncytium-inducing HIV strains in the majority of delta32 heterozygous seropositive patients suggests that its presence could not be a major factor in driving a switch toward more cytopathic, T-tropic HIV strains through selective pressure in coreceptor usage.

Collection of peripheral blood stem cells in pediatric patients: a concise review on technical aspects.

Peripheral blood stem cells (PBSC) are now routinely collected for use as hematopoietic support after high-dose chemotherapy for various malignancies. Nevertheless, few data are still available on PBSC collection in pediatric patients, owing to technical problems associated with the leukapheresis procedure in children. This paper briefly summarizes current knowledge about some technical aspects of pediatric leukapheresis for PBSC collection, according to the review of the literature and our personal experience on 60 procedures performed in 36 children affected with various malignancies. Technical issues include venous access, risk of volume shift due to exceeding extracorporeal circulation, and anticoagulation, that can induce severe side-effects. Moreover, criteria for optimizing the PBSC harvesting procedure in children, in particular the correct timing of leukapheresis, are discussed.

Autologous bone marrow transplantation in secondary acute monoblastic leukemia following Hodgkin's disease.

Acute non lymphocytic leukemia (AnLL) is the most common second malignancy (SM) in survivors of childhood Hodgkin's Disease (HD). Chemotherapy responsiveness is usually poor and death ensues briefly after diagnosis. We report the case of a 13 year-old girl, affected by HD, stage IV, mixed cellularity, who developed AnLL one year after the HD treatment was stopped. Autologous Bone Marrow Transplantation (ABMT) was performed 9 months after complete remission (CR) was achieved by chemotherapy. Presently, the patient is alive and on continues CR, 3 years and 7 months after ABMT. ABMT may be a promising approach for secondary AnLL, the prognosis of which is almost invariably fatal with conventional chemotherapy.

Peripheral blood stem cell collection and transplantation in paediatric malignancies: a monocentric experience.

Thirty-seven patients underwent peripheral blood stem cell (PBSC) collection from May 1994 to May 1997. Twenty-five were males and 12 were females, the median age at collection was 11.5 years (range 1-27.4) and the median weight was 38 kg (range 9-80). As mobilising chemotherapy, cyclophosphamide, etoposide, doxorubicin and cytosine arabinoside were the drugs most frequently used in association with G-CSF for a total of 47 courses. Sixty-one aphereses were performed with a median collection of CD34+ and CFU-GM cells/kg of 3.6 x 10(6) (range 0.6-31.8) and 24.4 x 10(4) (range 0.1-1260), respectively. Minimal residual disease (MRD) was found in five of the 30 investigated aphereses. Twenty-one of the 37 patients underwent high-dose chemotherapy with autologous stem cell rescue: in seven the stem cell source was peripheral blood and bone marrow. The median duration of hospitalization was 18 days for the PBSC group and 23 days for the PBSC/ABMT group. Overall survival was 78.7% at a median follow-up of 18 months (range 2-31) and the DFS was 52% without difference depending on stem cell source. Compared to a historical group of ABMT patients, the PBSC group showed a statistical advantage in terms of neutrophils and platelet engraftment, blood and platelet requirements, and length of hospitalization. PBSC collection is a feasible procedure also in the paediatric setting providing that vascular access is adequate. As already reported, PBSC transplant results in faster engraftment and shorter hospitalization that could allow a better utilization of health financial resources. The question whether the source of stem cells could influence transplant outcome would require a prospective randomised study.

Successful treatment of secondary acute myeloid leukemia relapsing after allogeneic bone marrow transplantation with donor lymphocyte infusion failed to prevent recurrence of primary disease: a case report.

We report a case of therapy-related secondary acute myeloid leukemia occurring in a patient during treatment for anaplastic large cell lymphoma. In spite of response to induction chemotherapy and prompt bone marrow transplantation from his matched sister, the patient experienced an early leukemia relapse within 3 months of the transplant. Treatment with oral etoposide for 3 weeks followed by donor lymphocyte infusion achieved a 7-month remission from leukemia without any further treatment. Unfortunately, the patient suffered a recurrence of the primary anaplastic large cell lymphoma that was treated by resuming chemotherapy and local radiotherapy. The patient died 20 months after DLI, still in CR for his leukemia, due to ALCL progression.

Effect of D-penicillamine on the T cell phenotype in scleroderma. Comparison between treated and untreated patients.

To investigate the possible immunomodulatory mechanism of D-penicillamine in Scleroderma (Scl), we analysed the surface phenotype of circulating T lymphocytes in 17 Scl patients, 6 of these studied before and after D-penicillamine treatment, 8 only before and 3 only after treatment. The drug was administered for 6 to 24 consecutive months with a median daily dose of 500 mg. The study of peripheral blood purified T cells was carried out using single-colour immunofluorescence and flow cytometry analysis (Ortho Diagnostic System) with monoclonal antibodies such as OKT4 (CD4, helper/inducer), OKT8 (CD8, cytotoxic/suppressor), OKDR and MLR4 (activated T cells), and Tec-5/9 (CD26, activated T cells with specific helper function for B cell differentiation). All of the patients showed lower CD8+ and higher MLR4+ and DR+ T cells than the controls, while CD26+ and CD4+ circulating T lymphocytes were lower in all of the treated in comparison with all of the untreated patients. A decrease in CD26+, CD4+ and total T cells was also observed after treatment in the 6 patients studied pre- and post-therapy. These results support the hypothesis that D-penicillamine selectively impairs the helper T cell subset in Scl patients.

Long-term therapy with plasma exchange in systemic sclerosis: effects on laboratory markers reflecting disease activity.

Plasma exchange (PEX) is a technique that has been applied to the treatment of many immunological disorders, including connective tissue diseases. The crucial role of some humoral factors in the pathogenesis of systemic sclerosis (SSc) could explain the good clinical results obtained in terms of slowing down the disease progression, but the efficacy of PEX in the treatment of SSc is not yet well defined, owing to the lack of controlled studies and validated parameters of disease activity. To demonstrate the long-term efficacy of PEX in the treatment of SSc we treated a group of 28 SSc patients affected with recent onset and/or rapidly progressive disease. Most of these had a diffuse form of SSc, with anti-Sc170 antibody as a disease marker. Before and after long-term PEX treatment we evaluated disease activity parameters including the serum levels of interleukin 2 soluble receptor (sIL-2R) and aminoterminal type III procollagen peptide (PIIINP), plus the percentage of DR+ T cells in the peripheral blood. We also assessed clinical parameters of total skin score and total visceral score. The same parameters were evaluated in 25 SSc patients who did not satisfy the admission criteria for PEX, treated long-term with drugs only. At baseline, serum PIIINP and sIL-2R levels and the percentage of DR+ T cells were significantly increased in PEX patients as compared to others. Following long-term PEX treatment, all the laboratory parameters significantly decreased and the clinical scores showed a slight but not significant improvement. Conversely, in the other group of SSc patients treated for the same period with drugs only, no significant change of laboratory parameters was detected and the clinical scores slightly worsened. Our data suggest that long-term PEX therapy seems to be effective in slowing down the clinical course of patients with severe and rapidly progressive SSc.

Immunosuppressive treatment in a heart transplantation candidate with antiphospholipid syndrome.

Dilated cardiomyopathy secondary to a devastating anterior myocardial infarction developed in a young patient with the antiphospholipid antibody syndrome. Due to severe left ventricular failure, heart transplantation was considered. To reduce antiphospholipid antibody titer, plasmapheresis followed by immunosuppressive treatment with cyclosporin and azathioprine were attempted in the pretransplant period. The antibody titer normalized after plasmapheresis, but then rose sharply despite immunosuppressive drugs. This case report underscores the failure of cyclosporin, a treatment not previously reported, to control autoimmunity in antiphospholipid syndrome. Moreover, progressive renal insufficiency can develop as a result of the long-term use of this drug.

A preliminary survey of the apheresis activity in Italy: a perspective for the Italian Registry of apheresis.

Data collection on the apheresis activity in Italy throughout 1997 was performed by means of a standardized questionnaire. These data, provided by 96 Apheresis Units from 13 Italian regions, albeit rough, are sufficiently informative. In 1997, a total number of 170,373 apheresis sessions was carried out, with a clear-cut prevalence of productive apheresis (92%) that was performed by all Apheresis Units. Lombardy, Venetia and Latium were the most active regions for therapeutic apheresis (56% of total activity).

A single institution's experience (1982-1999) with plasma-exchange therapy in patients with fulminant hepatic failure.

Fulminant hepatic failure is a rare, but often fatal complication of acute viral hepatitis. This condition, in absence of orthotopic liver transplantation (OLTx) surgery, is associated with a high mortality rate, despite the improvement of general intensive care. Plasma-exchange (PEx) therapy has been long used to treat FHF, in particular by removing toxic substances and correcting the severe coagulopathy. In this study we describe our experience with PEx treatment of FHF, beginning in 1982. Seventy patients affected with FHF due to various causes (HBV = 40; cryptogenic/non-A, non-E = 15; Amanita phalloides = 8; other = 7) were treated with PEx (altogether 348 sessions). Overall survival rate, comprising patients undergoing OLTx, was 51%, a little higher than what we observed in patients (N = 49) treated solely by PEx, i.e., 41%. The best outcome predictor was FHF aetiology, owing to the good survival rate in patients with Amanita phalloides intoxication and the very poor prognosis of patients suffering from cryptogenic/non-A, non-E FHF. Moreover, the marked increase in prothrombin time and alpha-fetoprotein levels after 48 hours from admission was associated with a good prognosis, whereas the patient's age and coma grade were not clearly predictive of survival. Additionally, lymphocyte subpopulation, resulting in a CD4/CD8 ratio lower than 1.0 along with CD8 activation with HLA-DR strong expression, were associated with a high rate of mortality and morbidity. Our data indicate that PEx therapy can improve survival in patients with sufficient residual capacity of liver regeneration. Moreover, the identification of certain prognostic factors may be useful for the rational planning of therapeutic strategy in FHF.

Changes in HCV viremia following LDL apheresis in a HCV positive patient with familial hypercholesterolemia.

It has been suggested that hepatitis C virus (HCV) can be associated with beta-lipoprotein in human serum. According to this, the LDL receptor could promote endocytosis of such a virus. In the present study, we evaluated the changes in HCV viremia in a HCV positive patient with familial hypercholesterolemia, undergoing both selective (DALI System, Fresenius) and non-selective (plasma exchange) LDL apheresis. HCV-RNA levels did not decrease following selective LDL apheresis, on the contrary showed a random, odd variation pattern (from -35% to +72%). Conversely, plasma exchange steadily induced a drop in HCV viremia (-35/43%), to a lower extent than that of a totally intravascular plasmaprotein, i.e., alpha 2-macroglobulin (-53/54%). These data indicate that beta-lipoprotein may not function as a plasma carrier of HCV, at least in the present case. Moreover, a continuous, quantitatively unforeseeable circulation of HCV virions from the intravascular plasma compartment to other extravascular and intracellular sites, seems to occur during an apheresis session.

ALEX (artificial liver for extracorporeal xenoassistance): a new bioreactor containing a porcine autologous biomatrix as hepatocyte support. Preliminary results in an ex vivo experimental model.

Long-term maintenance of viability and expression of differentiated hepatocyte function is crucial for bioartificial liver support. We developed a new bioreactor design (ALEX), associated with a new extracellular autologous hepatocyte biomatrix (Porcine Autologous Biomatrix - PBM) support. To test this new bioreactor, we compared it to a standard BAL (BioArtificial Liver) cartridge in a ex vivo model using human plasma added to bilirubin, ammonium and lidocaine. A pathology study was performed on both bioreactors. The results suggest that ALEX allows a maximal contact between the perfusing plasma and the liver cells and a proper hepatocyte support by a cell-to-matrix attachment. ALEX is a suitable cell support bioreactor, guaranteeing long-term maintenance of the metabolic activity of hepatocytes when compared to a standard BAL cartridge.

[Frequent occurrence of diabetes mellitus after corticosteroid treatment in mixed cryoglobulinemia. An HCV-related complication?]. / Frequente insorgenza di diabete mellito dopo trattamento cortisonico nella crioglobulinemia mista. Una complicanza HCV-correlata?

The hepatitis C virus (HCV) infection is characterized by a variety of extra-hepatic manifestations in many individuals. Among these, diabetes mellitus (DM) can be included, as such a metabolic disorder has been demonstrated to be more frequent in chronic hepatitis C than in liver disease due to other causes. Recently, we have observed that most patients affected with HCV-associated mixed cryoglobulinemia (13 out of 15, 86.7%), that were at baseline normoglycemic, developed DM following corticosteroid treatment (prednisone > 25 mg/daily) for at least three months. Conversely, when we consider a control group including 36 HCV negative patients affected with various immunomediated disorders, i.e., systemic lupus erythematosus, myasthenia gravis, poly/dermatomyositis and chronic inflammatory demyelinating polyneuropathy, that were initially normoglycemic, corticosteroid induced DM (prednisone > 25 mg/daily for at least three months) occurred only in 16.7% of subjects. Moreover, in other two HCV positive patients suffering from myasthenia gravis, prolonged corticosteroid treatment was complicated by DM. These data, that are still unclear from a pathophysiologic viewpoint, seem to indicate corticosteroid induced DM as a further, unusual extra-hepatic manifestation of the HCV infection.

[Anti-tissue autoantibodies in malignant pulmonary neoplasms]. / Gli autoanticorpi anti-tissutali nelle neoplasie polmonari maligne.

Tissue antibodies (Ab) were investigated in 85 patients affected with pulmonary malignancy of different histologic type and, as control, in 40 non-smoker healthy subjects and in 40 smoker subjects with chronic bronchitis. A significantly higher number of patients (64, 7%) had tissue Ab in comparison with both control groups (17% in non smoker group and 25% in smoker and chronic bronchitis group, respectively). Antinuclear antibodies were found in 29.4% of patients, antismooth muscle in 31.7%, anti-mitochondrial Ab in 4.7%, antityroid microsomes Ab in 4.7%, anti-gastric parietal cells Ab in 4.7%, anti-reticulin Ab in 11.7%. The patients at third stage of disease showed all antibodies as well as anti-nuclear more frequently that patients at first and second stage. Antibodies to cytoplasmic antigens were found in patients with anaplastic and squamous cancer, but not in patients with adenocarcinoma. Our observations suggest that immunologic abnormalities similar to those present in autoimmune disease, may be associated to pulmonary malignancy.

[Serotypes of hepatitis C virus in mixed cryoglobulinaemia]. / Caratterizzazione sierotipica del virus dell'epatite C nella crioglobulinemia mista.

BACKGROUND: Several authors have studied the genotypic distribution of hepatitis C virus (HCV) in mixed cryoglobulinaemia (MC), which represents the most typical extra-hepatic manifestation of the HCV infection. On the other hand, at present no data are available on the HCV serotypic characterization of MC patients. METHODS: Thus, 28 serum specimens from HCV positive patients affected by MC (7 males and 21 females; mean age of 64 yrs, range 35-80) have been evaluated by a serotyping EIA method (Murex HCV Serotyping 1-6 Assay, Murex Diagnostics, Pomezia, Italy). RESULTS: The HCV serotype 1 was found in 13 patients (46.4%), serotype 2 in 5 patients (17.9%) and mixed serotypes in 3 patients (10.7%), showing, respectively, serotypes 1+2, 1+4, and 1+4+5. Moreover, the HCV serotype was not detectable in 7 patients (25.0%). CONCLUSIONS: These results, obtained by using a simple, serologic technique, agree with some literature data concerning MC patients from the same geographic region as ours (Venetian area). In addition, our findings appears to reflect merely the genotypic distribution of the HCV infection in the North Italy.