Looking for predictive factors of clinical response to adsorptive granulocyte and monocyte apheresis in patients with ulcerative colitis: markers of response to GMA

Abstract

Background: Adsorptive granulocyte and monocyte apheresis (GMA) with an Adacolumn in patients with ulcerative colitis (UC) has been applied as a non-pharmacological treatment strategy, but the efficacy has been encouraging as well as discouraging, depending on patients' demography at entry. In this study, we looked for predictive factors for clinical response to GMA in patients with UC.

Methods: In a retrospective setting, 43 outpatients who had been treated with GMA for active UC were evaluated. Patients were divided into remission group and non-remission group based on Lichtiger's clinical activity index (CAI) before and after 10, once a week GMA sessions. The efficacy was analysed in relation to patients' demographic variables. To determine predictive factors that closely related to the response to GMA, receiver operating characteristic (ROC) curve, and multiple logistic regression analyses were applied.

Results: After 10 GMA sessions, the overall clinical remission rate (CAI < 4) was 53.5%. Multiple logistic regression and ROC analyses showed that the interval between relapse and the first GMA session was a significant and independent predictive factor for clinical response to GMA (P = 0.016); the clinical response was better in patients who received GMA immediately after a relapse and vice versa. Likewise, univariate analyses showed that, the duration of UC (P = 0.036) and the cumulative prednisolone (PSL) dose (P = 0.006) before the first GMA session were significantly greater in the GMA non-responder group as compared with the responder group. Additionally, a lower white blood cell (WBC) count at first GMA session was related to clinical response to GMA (P = 0.032).

Conclusions: In this study, patients with a short duration of UC and low cumulative PSL dose seemed to respond well to GMA. However, we found that the best responders were patients who received GMA immediately after a clinical relapse. Additionally, GMA was effective in patients with low WBC count at the first GMA session. The findings of this study should spare medical cost and reduce morbidity time for many patients, relevant for decision making in clinical settings.

Figure 1

Treatment of patients and summary of the clinical outcomes. GMA, adsorptive granulocyte and monocyte apheresis; PSL, prednisolone; AZA, azathioprine; 5-ASA, 5-aminosalicylic acid.

Figure 2

The clinical efficacy of GMA based on changes in Lichiger’s clinical activity index (CAI) evaluated at entry, after 5 and 10 GMA sessions.

Figure 3

Endoscopic findings in 3 typical responders to GMA. All patients achieved complete remission after weekly GMA sessions. One of these patients (Figure 3a) with the first UC episode had absence of vascular patterns, spontaneous bleeding, erythema, oedema and friability at entry. This patient showed an early response to GMA, after receiving just 5 GMA sessions and achieved mucosal healing (MH) a few months later (Figure 3b). The second patient with steroid-dependent UC had extensive ulcers, oedematous mucosa at entry (Figure 3c). This patient achieved clinical remission and partial MH after 10 GMA sessions (Figure 3d). The third patient had a short duration of UC and absence of vascular patterns, spontaneous bleeding, erythema, ulcers and friability at entry (Figure 3e). This patient achieved MH a few months later after 10 GMA sessions (Figure 3f). These 3 patients had maintained remission at week 54 following the last GMA session.

Figure 4

Endoscopic findings in a typical non-responder to GMA. At entry, this patient had extensive deep lesions and loss of mucosal tissue at UC lesion sites. GMA was discontinued after 5 sessions as it was judged futile to administer further GMA sessions to this patient.

Figure 5

Receiver operating characteristic (ROC) curves for the interval between relapse and the first GMA, WBC at the first GMA and cumulative PSL dose before the first GMA session in patients with active ulcerative colitis.