Immunoadsorption for systemic lupus erythematosus.

Immunoadsorption (IAS) with various methods is used as a rescue therapy in severely ill SLE patients who are refractory to conventional therapeutic procedures. The method aims at the rapid and extensive removal of pathogenic immunocomplexes (IC) and (auto-) antibodies (Abs). Long-term observational studies suggested efficacy and have not seen an increase in the risk of infections (as were seen in other extracorporeal procedures). Unfortunately, prospective, randomized controlled trials (RCT) are lacking. Recently, biologicals aiming at TNF-blockade or B-cell depletion have been used to treat severe SLE: They are easier to apply since they do not necessitate additional (expensive) hardware or specially trained staff. While there is emerging evidence for efficacy from uncontrolled observations, no RCT could so far demonstrate benefit in SLE. Under these circumstances, IAS still has a role in treating severe SLE, when other therapies are not effective enough or are contraindicated (as in pregnancy). These data are reviewed and illustrated in the case of a pregnant lupus patient with nephrotic syndrome.