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LDL Apheresis
Low-density lipoprotein (LDL) apheresis (LA) removes apo-B containing lipoprotein (LDL and lipoprotein(a) [Lp(a)]). The primary indication for LA is familial hypercholesterolemia (FH), an autosomal dominant disorder of cholesterol metabolism, resulting in elevated plasma LDL-C levels.
Numerous LDL-C removal methodologies are used by various systems available worldwide. Available technologies include heparin-induced extracorporeal LDL-C precipitation, dextran sulfate cellulose adsorption, double filtration plasmapheresis, polyacrylate full blood adsorption, and immunoadsorption—all have similar efficacy ( Table 80.1 ). Only Liposorber LA-15 (Kaneka Pharma America LLC, New York, NY) and Plasmat Futura (previously Plasmat Secura) (B. Braun Medical, Bethlehem, PA) systems are FDA-approved.
Table 80.1
Comparison of Currently Available Low-Density Lipoprotein (LDL) Apheresis Systems
Modified from Winters, J. L., in McLeod, B. C., Weinstein, R., Winters, J. L., et al. (Eds.). (2010). Apheresis Principles and Practice (3rd ed.). Baltimore: AABB Press.
| System/Commercial Instrument | Mechanism of LDL Removal | Substances Removed a | Advantages | Disadvantages |
|---|---|---|---|---|
| Dextran Sulfate Liposorber LA-15 b | Binding to dextran sulfate on the basis of electrical charge | LDL: 56%–65% HDL: 9%–30% TG: 34%–40% Lp(a): 52%–61% | Column can be regenerated | System requires plasma separation, which may be interfered by a high hematocrit |
| Heparin-induced extracorporeal LDL precipitation. Plasmat Secura and Plasmat Futura b | Precipitation of LDL by heparin at an acidic pH | LDL: 67% HDL: 15% TG: 41% Lp(a): 62% | System removes fibrinogen | System is complicated. High hematocrit may interfere with plasma separation |
| Double filtration plasmapheresis | Separation based on size by filtering plasma with a second filter | LDL: 56% HDL: 25% TG: 49% Lp(a) 53% | System removes fibrinogen | High hematocrit may interfere with plasma separation. System causes loss of some albumin, HDL, and IgG |
| Plasmaselect | Immobilized sheep apolipoprotein B-100 antibodies | LDL: 64% HDL: 14% TG: 42% Lp(a): 64% | Column can be regenerated | System causes exposure to animal proteins |
| Lipoprotein hemoperfusion DALI | Binding to polyacrylate-coated polyacrylamide beads on the basis of electrical charge | LDL: 61% HDL: 30% TG: 42% Lp(a): 64% | Plasma separation is not necessary | Column cannot be regenerated or reused |
| Liposorber D | Binding to dextran sulfate covalently bonded to cellulose, on the basis of electrical charge | LDL: 62% HDL: 2.5% TG: 38%–68% Lp(a): 56%–72% | Plasma separation is not necessary. Procedure time is shorter than Liposorber LA-15 | Column cannot be regenerated |
Anticoagulant
LA instruments use heparin, either alone or in combination with citrate, as the anticoagulant. Citrate cannot be used in the Liposorber LA-15 system because this system removes cholesterol selectively based on the electrostatic interaction between the column and apoB100 lipoproteins and citrate can interrupt this interaction. In a patient with heparin-induced thrombocytopenia, lepirudin was reportedly used as the anticoagulant for the direct adsorption of lipoprotein (DALI) system. A small case series describing the use of citrate, as the only coagulant for this DALI system was also published.
Adverse Events and Contraindications
LA has an overall adverse event rate of 11%, and without significant difference between different LA systems. Most of these reactions are mild. The most common side effects are postprocedure bleeding (3.5%), vomiting (2.5%), hypoglycemia (2.4%), and hypotension (2.2%). The use of angiotensin-converting enzyme inhibitors (ACEIs) is contraindicated in adsorption-based LA, and discontinuation is recommended 24 hours before procedure. Angiotensin receptor blockers can be used as alternatives. Recently, the use of turmeric herbal therapy has been associated with symptoms similar to those observed in patients taking ACEI.
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