[Immunoglobulins or plasma exchange? Synchronization of plasma exchange and intravenous polyvalent immunoglobulins. A consecutive study of 11 patients].

Synchronization is defined as a prescription sequence aimed at obtaining synergic response or potentialization. THEORETICAL BASIS--The concept of synchronization is based on clinical and biological observations such as similar indications and transient effectiveness. Certain mechanisms of action such as reduction of pathological autoantibodies and accelerated elimination of immune complexes are common to both methods. Inversely, long-term effects differ. Plasma exchange cannot control the synthesis (or could aggravate) of autoantibodies while gammaglobulins have a suppressor effect on autoreactive clones. The aim is to obtain a summation effect by eliminating immediately cytotoxic factors. The potentializing effect of gammaglobulin anti-idiotypes on the modification of the immunologic repertory is favoured by prior reduction in the level of circulating pathogenic antibodies. RESULTS--It is difficult to evaluate the efficacy of this therapeutic association. Only a few trials have been conducted in refractory autoimmune thrombopenic purpura (n = 8), in intra-uterine Rhesus disease (n = 3), and HIV associated pathologies. We report our experience in 11 patients in a situation of therapeutic failure including three cases of renal transplantation, two cases each of chronic polyradiculoneuritis and neurological paraneoplastic syndromes, and one case each of Wegener's syndrome, polymyositis, sclerokeratitis, and antiphospholipid antibodies during pregnancy. Immunoglobulins were injected at an initial dose of 2 g/kg following at least 3 plasma exchanges. Consolidation cures were then administered every 3 weeks at a dose of 1 g/kg. Two major complications occurred and required interruption of the treatment: acute regressive oligo-anuric renal failure (Wegener) and exacerbation of sclerokeratitis inflammatory lesions. The disease process was controlled in 7 patients. CONCLUSIONS--Despite these promising preliminary results, the proposed combination therapy is not devoid of complications and its cost is high (cost of PE for 500 mg/kg Ig is about 5,000 FF). The next step should be the study of experimental models and prospective trials on pathologies with well characterized immunological features.