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that time. Serum samples were collected Table 1. Baseline characteristics of patients from both groups
from the patients just before the first
apheresis procedure and one week after LCAP group Control group
the last one. These samples were stored Characteristics (n = 20) (n = 31)
at -80°C until the cytokine analysis was Demographics
performed. Sex (% female) 87.50% 87.10%
Age, years 46.00 ± 16.06 49.00 ± 12.84
Intervention RA activity
LCAP was performed using a direct Mean disease duration, months 22.16 24.95
hemoperfusion column, a Cellsorba Tender joint count (range, 0–28) 14.31 ± 9.4 10.45 ± 7.91
column (CS-180S; Asahi Kasei Medical, Swollen joint count (range, 0–28) 8.68 ± 7.71 9.54 ± 6.14
Tokyo, Japan), to remove circulating Patient assessment of pain, VAS (range, 0–10) 5.18 ± 1.51 5.90 ± 1.01
leukocytes from the patients’ blood. The Patient assessment of global severity, VAS (range, 0–10) 5.37 ± 1.66 6.20 ± 0.94
column is packed with fine-diameter Physician assessment of global severity, VAS (range, 0–10) 5.28 ± 1.50 5.67 ± 0.90
polyethylene terephthalate fibers that are ESR,mm/h 38.75 ± 27.55 46.35 ± 30.99
commonly used for adsorbing white CRP,mg/dL 4.46 ± 3.91 3.01 ± 2.34
blood cells to prevent febrile, DAS28 5.81 ± 1.29 5.80 ± 1.36
nonhemolytic transfusion reaction HAQ-DI 6.93 ± 6.89 5.58 ± 3.87
during blood transfusion. 3,19
Briefly, when whole blood is passed Note: values are the mean ± SD.
through the fiber layer in the cylinder,
leukocytes—including monocytes, Abbreviations: LCAP, leukocytapheresis; RA, rheumatoid arthritis;
neutrophils, and lymphocytes—are HAQ-DI, Health Assessment Questionnaire Disability Index; VAS, visual analog
trapped and filtered by the fiber layer. In scale; CRP, C-reactive protein; ESR erythrocyte sedimentation rate.
each apheresis procedure in the current
study, 3000 mL of whole blood were filtered and returned to The DAS has been developed as a quantitative index to
each patient. The column was mounted on the machine for be able to measure, study and manage disease activity in RA
extracorporeal circulation (PlasautoiQ21, Asahi Kasei in daily clinical practice, clinical trials, and long term
Medical) and was perfused with blood at a flow rate of observational studies. The most widely used method for RA
50 mL/min for 60 minutes with the aid of a peristaltic pump. activity evaluation is the DAS and its simplified version –
Sodium heparin was infused into the outlet line initially at a DAS28. DAS score was developed in Nijmegen, the
rate of 30 mg/h and then at 10 mg/h as a local anticoagulant. Netherlands. The development began in 1983 for the purpose
The apheresis procedure was performed every 5 days for a of assessment of RA activity for a clinical study and was
total of 5 treatments. continued for several years thereafter. DAS/DAS28 is a
continuous measure of RA disease activity that combines
Outcome Measures information from Swollen-joint count, Tender-joint count,
American College of Rheumatology (ACR) recommend acute phase response including ESR, CRP, and patient
the Clinical Disease Activity Index, Disease Activity Score self-report of general health which call The VAS assesses
(DAS) with 28-joint counts (erythrocyte sedimentation rate patients’ pain. Cut points were developed to classify patients
or C-reactive protein), Patient Activity Scale (PAS), PAS-II, in remission, as well as low, moderate, and severe disease
Routine Assessment of Patient Index Data with 3 measures, activity in the 1990s.
and Simplified Disease Activity Index because they are DAS28 score is currently used in clinical practice more
accurate reflections of disease activity; 20,21 are sensitive to commonly than the DAS score because it requires assessment
change; discriminate well between low, moderate, and high of fewer joints (only 28 joints are assessed for the DAS28
disease activity states; have remission criteria; and are feasible score). Twenty-eight tender and swollen joint scores include
to perform in clinical settings. the same joints: shoulders, elbows, wrists, metacarpophalangeal
Most clinical studies on RA have included clinical joints, proximal interphalangeal joints and the knees.
outcomes, such as the ACR definition of improvement, the More recently, an alternative formulation of the DAS28
DAS, and disease-specific quality of life (QoL), such as health based on CRP has been proposed and developed.
assessment questionnaire disability index (HAQ-DI). In clinical trials the DAS28 can be used to assess whether
In rheumatoid arthritis, disease activity cannot be an individual patient has a significant improvement of the
measured using a single variable. Current EULAR diagnostic disease activity, compared to baseline. For this aim, the
criteria for RA include disease activity parameters, such as EULAR response criteria can be used. The DAS28 can be
erythrocyte sedimentation rate (ESR) and C-reactive protein calculated with the CRP instead of the ESR. The C-reactive
(CRP), which are used to calculate disease activity scores, protein (CRP) may be used as an alternative to ESR in the
including DAS and DAS28. calculation of the DAS or the DAS28. The DAS28 can be

38 ALTERNATIVE THERAPIES, JUL/AUG 2020 VOL. 26 NO. 4 Huang—Leukocytapheresis Therapy for Rheumatoid Arthritis