The use of plasmapheresis in the complex therapy of idiopathic fibrosing alveolitis

Idiopathic fibrosing alveolitis (EIA) is one of the most common and, at the same time, poorly studied diseases from the group of interstitial lung diseases. Idiopathic fibrosing alveolitis is characterized by inflammation and fibrosis of pulmonary interstitium and airborne spaces, disorganization of the structural and functional units of the parenchyma, which leads to the development of restrictive changes in the lungs, disruption of gas exchange, progressive respiratory failure and, ultimately, the death of the patient.

In the study of the pathogenesis of idiopathic fibrosing alveolitis, most researchers now tend to an autoimmune reaction in combination with a viral infection. The presence of rheumatoid and antinuclear factors in the blood of patients with idiopathic fibrosing alveolitis, an increased number of circulating immune complexes, y-globulins, and the detection of histiolymphocytic infiltration in the interstitium of the lungs indicate immune disorders in this disease.

In the basic treatment of idiopathic fibrosing alveolitis, a long-term use of anti-inflammatory drugs capable of affecting the immunological links of pathogenesis is actively used: corticosteroids and cytostatics. However, it should be recognized that modern medicine does not yet have effective methods of treating idiopathic fibrosing alveolitis. The entire used arsenal of drug therapy has virtually no effect on the prognosis of the disease.

The disease is extremely difficult, accompanied by an increasing respiratory insufficiency, which in most cases leads to a fatal outcome.
In this regard, the development of new methods and approaches to treatment is very relevant. As an additional means of anti-inflammatory effect, extracorporeal methods of treatment are often used.

In GASR RKB MZ RT in the treatment of patients with idiopathic fibrosing alveolitis, we actively use the method of combining basic therapy with the course of operations of plasmapheresis. Over the past 10 years, 480 plasmapheresis operations were performed in 91 patients with EIA at the age of 22 to 70 years old, 64 of them women and 27 men in the laboratory of gravitational blood surgery (CGCC). All patients received baseline therapy according to the recommendations of the European Respiratory Society (ERS) and the American Thoracic Society (ATS) (2000), which included glucocorticosteroids 0.5-1.0 mg / kg per day in terms of prednisolone, with a pronounced tendency to fibrosis, cytostatics - azathioprine 2-3 mg / kg per day, the maximum daily dose is 150 mg or cyclophosphamide 2 mg / kg per day, the maximum daily dose is 150 mg.

Plasmapheresis operations were performed using a multifunctional centrifuge with automatic cooling of SORVAL RS 3C PLAS and on devices PCS 2 - Hemonetics.

The course of plasmapheresis consisted of 2-3 operations at intervals of 2 to 4 days. The volume of plasma exfusion in one procedure is 35-50% of the volume of the circulating plasma, which was replaced in a moderate hypervolemic regime with a 0.9% solution of sodium chloride and rheopolyglucin in a 2: 1 ratio.

The course of operations of plasmapheresis was combined with basic therapy with glucocorticosteroids (GCS) and cytostatics (azathioprine or cyclophosphamide). Repeated courses are conducted after 4-6-12 months, that is, patients were on a "programmed" plasmapheresis.

As a result, they noted:

• reduction of clinical manifestations - reduction of weakness, dyspnea, cough, increased tolerance to physical exertion;
• improvement in the parameters of external respiration function, diffusive capacity of the lungs, gas composition of blood - increase in the volume of forced expiratory volume in the first second (FEV1) by 12.7% from the initial, vital capacity of the lungs (YHEL) by 9.2% of the initial, increase in the level of saturation blood (SPO2);
• positive dynamics on radiographs and computer tomograms (CTG) of the lungs - slowing or stopping fibrosis of pulmonary tissue;
• decrease in the dose of basic therapy drugs;
• stabilization of the process - reduction or cessation of disease progression.

It is not necessary to expect the reverse development of already occurring organic lesions of the lungs - fibrosis, but it is possible that the effect on the initial stages of the disease - alveolitis and interstitial edema. When excreted from the body as primary toxic agents for alveolar structures, and, obviously, secondary products of the immune response, one can expect to improve or at least stop the spread of pathological processes in the lung parenchyma.

Clinical experience confirms these assumptions, plasmapheresis courses improve the gas exchange function of the lungs, slow its progression with a much lower level of drug support by hormonal and cytostatic drugs. According to our observations, with "programmed" plasmapheresis, similar results are achieved much faster with the use of smaller doses of basic drugs.

This allows us to recommend "programmed" plasmapheresis in cases of pronounced inflammatory infiltration of pulmonary tissue detected on radiographs and computer tomograms (CTG); with long-term administration of high doses of glucocorticosteroids and / or cytostatics, and also in the absence of the effect of drug therapy.

"Programmed" plasmapheresis in fibrosing alveolitis increases the effectiveness of standard medicamentous anti-inflammatory therapy and allows reducing its volume, reducing tolerance to medicines, almost completely avoiding the appointment of cytotoxic drugs, which prevents exacerbations and improves the quality of life in a timely manner, and even keeps the patients working. The overall life expectancy of these patients also increases significantly with complex therapy, including plasmapheresis.

Doctor anesthesiologist-resuscitator of the cabinet of gravitational blood surgery Sagitova Olga Vladimirovna. Application of plasmapheresis in the complex therapy of idiopathic fibrosing alveolitis // Practical medicine. 8 (64) December 2012 / volume 1