Extracorporeal photoapheresis (ECP) is a form of apheresis-based immunomodulatory therapy which is currently used in many different clinical settings such as cutaneous T-cell lymphoma, graft-versus-host disease, rheumatic diseases, pemphigus vulgaris, and acute allograft rejection treatment in cardiac, lung, liver, and kidney transplant1.
During ECP mononuclear leucocytes are separated from whole blood using centrifugation. A photosensitizing agent (8 metoxipsoralen) is added and the white cells are then irradiated with ultraviolet light A before being returned to the patient. The key mechanism of this ECP is induction of leukocyte apoptosis. After reinfusion to the patient, the apoptotic white cells are engulfed by antigen-presenting cells triggering a T citotoxic induced autoimmunity effect against T pathologic lymphocytes, what have been called "auto-vaccination theory", and a T cell regulatory effect that induce tolerance to pathologic cells, contributing in this case to the receptor graft tolerance1-4.
At the best of our knowledge there are few articles reporting the use of ECP in renal diseases, most of them as adjuvant treatment for handling refractory acute kidney rejection, and only one for treating nephrotic syndrome. All of them reported good results with a non toxic, well tolerated, and non immunosuppressive (but immunomodulatory) treatment5-11.
However, since T lynphocytes, target of this treatrment, are involved in many renal pathophysiology mechanisms of renal diseases beyond graft rejection and nephrotic syndrome, as is the case of proliferative glomerulopathies (crescent glomerulonephritis) and interstitial nephritis of diverse etiologies12-13.
In conclusion, we postulate that perhaps extracorporeal photoapheresis could be an interesting therapeutic alternative for handling refractory CD4+ T lymphocytes mediated nephropathies.
1.- Kumlien G, Genberg H, Shanwell A, Tydén G. Photopheresis for the treatment of refractory renal graft rejection. Transplantation. 2005;79:123-125.
2.-Gilliet M, Cozzio A, Burg G, Nestle F. Successful treatment of three cases of nephrogenic fibrosing dermopathy with extracorporeal photopheresis. British Journal of Dermatology. 2005; 152: 531–536
3.- Edelson RL. Extracorporeal Photopheresis. Photodermatol. 1984; 5:209-210.
4.- Edelson R. Treatment of cutaneous T-Cell Lymphoma by extracorporeal photochemotherapy. N Engl J Med. 1987; 316: 297-303.
5.- Lai Q, Pretagostini R, Gozzer M, Cinti P, Meo D, Vita F, Shafii Bafti M, Poli L, Novelli G, Rossi M, Girelli G, Berloco PB. Multimodal therapy with combined plasmapheresis, photoapheresis, and intravenous immunoglobulin for acute antibody-mediated renal transplant rejection: a 2-year follow-up. Transplant Proc. 2011;43:1039-1041.
6.- Genberg H, Kumlien G, Shanwell A, Tydén G. Refractory acute renal allograft rejection successfully treated with photopheresis. Transplant Proc. 2005;37:3288-3289.
7.- Kusztal M, Kos'cielska-Kasprzak K, Gdowska W, Zabin'ska M, Myszka M, Klak R, Krajewska M, Boratyn'ska M, Szyber P, Chudoba P, Patrzalek D, Klinger M. Extracorporeal photopheresis as an antirejection prophylaxis in kidney transplant recipients: preliminary results. Transplant Proc. 2011;43:2938-2940.
8.- Kusztal M, Klak R, Krajewska M, Boratyn'ska M, Patrzalek D, Klinger M. Application of extracorporeal photopheresis in kidney transplant recipients: technical considerations and procedure tolerance. Transplant Proc. 2011;43:2941-2942.
9.- Russo GE, D'Angelo AR, Testorio M, Mazza F, Borzacca B, Cicchinelli A, Laudani G, Serriello I, Casarci M, Guido A, Cavallini M. New therapeutic prospects for renal transplant: extracorporeal photochemotherapy].G Ital Nefrol. 2012;29 Suppl 54:S36-39.
10.- Lai Q, Pretagostini R, Gozzer M, Cinti P, Meo D, Vita F, Bafti MS, Poli L, Novelli G, Rossi M, Girelli G, Berloco PB. [Multimodal treatment for acute antibody-mediated renal transplant rejection: successful rescue therapy with combined plasmapheresis, photopheresis and intravenous immunoglobulin]. G Ital Nefrol. 2012;29 Suppl 54:S31-35.
11.- Russo G, Cavallini M, Centi A, Baliva G, Carraro M, Pugliese F. Extracorporeal photochemotherapy for the treatment of glomerulopathies with associated nephrotic syndrome. J Nephrol. 2010; 23(01): 85-89.
12.- Ponticelli C, Glassock R. Treatment of primary glomerulonephritis. Oxford. Oxford University Press. 2009.
13.- Rennke H, Denker B. Renal pathophysiology. Philadelphia. Lippincott Williams & Wilkins. 2007.