Our Clinical Experience in the Treatment of Myasthenia Gravis Acute Exacerbations with a Novel Nanomembrane-Based Therapeutic Plasma Exchange Technology

Abstract

According to the American Academy of Neurology 2011 guidelines, there is insufficient evidence to support or refute the use of therapeutic plasma exchange (TPE) for myasthenia gravis (MG). The goal of this study was to determine whether a novel nanomembrane-based TPE could be useful in the treatment of MG. Thirty-six adult patients, MGFA 4/4B and 5, with acute MG episodes were enrolled into a single-center retrospective before-and-after study to compare a conventional treatment group (n = 24) with a nanomembrane-based TPE group (n = 12). TPE or intravenous immunoglobulins (IVIG) infusions were used in impending/manifested myasthenic crises, especially in patients at high-risk for prolonged invasive ventilation (IMV) and in those tolerating non-invasive ventilation (NIV). The clinical improvement was assessed using the Myasthenia Muscle Score (0–100), with ≥20 increase for responders. The primary outcome measures included the rates of implemented TPE, IVIG, and corticosteroids immunotherapies, NIV/IMV, early tracheotomy, MMS scores, extubation time, neuro-ICU/hospital LOS, complications, and mortality rates. The univariate analysis found that IMV was lower in the nanomembrane-based group (42%) compared to the conventional treatment group (83%) (p = 0.02). The multivariate analysis using binary logistic regression revealed TPE and NIV as independent predictors for short-term (≤7 days) respiratory support (p = 0.014 for TPE; p = 0.002 for NIV). The novel TPE technology moved our clinical practice towards proactive rather than protective treatment in reducing prolonged IMV during MG acute exacerbations.

Nanomembrane-Based Apheresis: A Simple and Safe Procedure for Preventing Cardiovascular Complications in Metabolic Syndrome

“…The nanomembrane is made of Lavsan film irradiated by accelerated charged argon particles in a collider, creating pores with diameters of 30-50 nm. This allows it to filter molecules with a weight of less than 40 kDa [21][22][23]. In nanomembrane-based LVPE, the most frequently used replacement fluid is saline solution, which has no side effects even when 25-30% of the circulated plasma is separated [24].…”

“…This approach preserved plasma quality and achieved our purification goal. Conducting four cycles of LVPE every other day removed up to 1-1.5 times the volume of circulating plasma [23].…”

Oxidative Stress and the Nuclear Factor Erythroid 2-Related Factor 2 (Nrf2) Pathway in Multiple Sclerosis: Focus on Certain Exogenous and Endogenous Nrf2 Activators and Therapeutic Plasma Exchange Modulation

“…TPE is an effective and relatively safe method that can be applied in the treatment of neurodegenerative diseases [17,184]. However, the use of TPE in the management of acute relapsing MS is still modest [184] and also has inherent limitations in terms of local specificities related to the population under investigation, experience, availability, and insurance coverage [17,165].…”

“…The most important limitations and advantages of the various Nrf2 activators are summarized in Table 2 [10,17,112,[123][124][125][150][151][152][153]165,185,186]. Nrf2 is reported to either suppress or induce inflammation and immunity in a cell-typeand disease-dependent manner [69].…”

“…There are pores in the nanomembrane with a diameter of 30-50 nm, which allow the filtration of molecules with a molecular weight below 40 kDa. The device has a volume of up to 70 mL [165]. The most widely used replacement is saline (NaCl 0.9), which is cheap and has no adverse effects, even when 25% of the circulating plasma is replaced [162].…”