The lipid- and lipoprotein- [LDL-Lp(a)] apheresis techniques. Updating.

Therapeutic plasmapheresis allows the extracorporeal removal of plasmatic lipoproteins (Lipid-apheresis) (LA). It can be non selective (non specific), semi - selective or selective low density lipoprotein-lipoprotein(a) (specific [LDL- Lp(a)] apheresis) (Lipoprotein apheresis, LDLa). The LDL removal rate is a perfect parameter to assess the system efficiency. Plasma-Exchange (PEX) cannot be considered either specific nor, selective. In PEX the whole blood is separated into plasma and its corpuscular components usually through centrifugation or rather filtration. The corpuscular components mixed with albumin solution plus saline (NaCl 0.9%) solution at 20%-25%, are then reinfused to the patient, to substitute the plasma formerly removed. PEX eliminates atherogenic lipoproteins, but also other essential plasma proteins, such as albumin, immunoglobulins, and hemocoagulatory mediators. Cascade filtration (CF) is a method based on plasma separation and removal of plasma proteins through double filtration. During the CF two hollow-fiber filters with pores of different diameter are used to eliminate the plasma components of different weight and molecular diameter. A CF system uses a first polypropylene filter with 0.55 µm diameter pores and a second one of diacetate of cellulose with 0.02 µm pores. The first filter separates the whole blood, and the plasma is then perfused through a second filter which allows the recovery of molecules with a diameter lower than 0.02 µm, and the removal of molecules larger in diameter as apoB100-containing lipoproteins. Since both albumin and immunoglobulins are not removed, or to a negligible extent, plasma-expanders, substitution fluids, and in particular albumin, as occurs in PEX are not needed. CF however, is characterized by lower selectivity since removes also high density lipoprotein (HDL) particles which have an antiatherogenic activity. In the 80's, a variation of Lipid-apheresis has been developed which allows the LDL-cholesterol (LDLC) (-61%) and Lp(a) (-60%) removal from plasma through processing 3 liters of filtered plasma by means of lipid-specific thermofiltration, LDL immunoadsorption, heparin-induced LDL precipitation, LDL adsorption through dextran sulphate. More recently (90's) the DALI®, and the Liposorber D® hemoperfusion systems, effective for apoB100- containing lipoproteins removal have been developed. All the above mentioned systems are established LDL-apheresis techniques referable to the generic definition of LDLa. However, this last definition cannot describe in an appropriate manner the removal of another highly atherogenic lipoprotein particle: the Lp(a). Thus it would be better to refer the above mentioned techniques to the wider scientific and technical concept of lipoprotein apheresis.

Cytokines profile in serum of homozygous familial hypercholesterolemia is changed by LDL-apheresis.

OBJECTIVE: The effects of LDL-apheresis (LDLa) with dextran sulphate on plasma cytokines in 6 homozygous familial hypercholesterolemic (HozFH) patients, were evaluated. METHODS: Plasma IL-1α; IL-1ra; IL-4; IL-6; IL-10; IL-12(p40); IL-12(p70); TNF-α, sTNF-R, VEGF, VEGF-R1, E-Selectin (ESEL), and P-Selectin (PSEL) concentrations were measured before and after LDLa on three consecutive sessions for each patient. RESULTS: TNF-α was significantly reduced (-60%; P=0.01), while TNF-R was only slightly increased (+15%), although not significantly. Plasma VEGF was significantly reduced (-57%; P=1.87301E-05), while VEGF-R1 was significantly increased (+56%; P=0.05). ESEL and PSEL were reduced but not to a statistically significant extent (-19%, -15%, respectively). IL-1α level was dramatically reduced (-87%; P=0.0001). IL-1ra concentration was only slightly increased in plasma, but not significantly. IL-4 and IL-10 levels were significantly reduced in plasma after apheresis (-50%; P=0.03, and -55%; P=0.004, respectively). On the contrary, IL-6 concentration showed a slight decrease (-8%). Plasma IL-12p40 was significantly increased (+47%; P=0.0004). On the other hand, IL-12p70 was reduced, but the difference (-31%) was not statistically significant. CONCLUSIONS: Plasma cytokines imbalance is associated with inflammation and atherogenesis. In this study LDLa changed several circulating cytokines inducing anti-inflammatory and anti-atherogenic changes in cytokines plasma profile in HozFH patients with/without pre-existing angiographically demonstrated coronary heart disease (CHD) and aortic valvular disease (AVD).

Treatment of symptomatic hyperLp(a)lipidemia with LDL-apheresis vs. usual care.

BACKGROUND/AIMS: To assess LDL-apheresis efficacy to lower Lp(a) and to compare the effects of Usual Medical Care (UMC) a 12-months study was carried out. The incidence of new coronary artery disease (CAD) events/need of revascularization, was also monitored. METHODS: Twenty-one patients with hyperLp(a)lipidemia and angiographically documented CAD were randomly assigned to LDL-apheresis every week, or the UMC. RESULTS: LDL-apheresis group, averaged an Lp(a) reduction of 57.8+/-9.5% vs. basal values (P<0.001). In the UMC group Lp(a) increased in 1 year to 14.7+/-36.5% (P=0.66). Stepwise multivariate regression analysis for predictors of Lp(a) including: type of treatment, smoking, hypertension, age, age at first cardiovascular event, initial Lp(a), LDL, and BMI values, was performed. Only the type of treatment was co-related (P<0.001): Lp(a) variation (beta)=0.863. The model has R2 adjusted relative risk of 0.725. CONCLUSION: LDL-apheresis could be the first line treatment of isolated hyperLp(a)lipidemia when CAD is established. New CAD events/cardiac interventions were not observed.

Diet only and diet plus simvastatin in the treatment of heterozygous familial hypercholesterolemia in childhood.

This study was a 1-year clinical study on 16 (7 males and 9 females) pediatric patients with heterozygous familial hypercholesterolemia treated with hypocholesterolemic diet only, or with diet plus drug (simvastatin 10 mg/day). According to the study protocol, the children were submitted to a 3-month washout (free diet). Then they were given a diet (American Heart Association, step 2) for 6 months. After 6 months they were divided into two groups matched for sex, age and body mass index (BMI). Diet only was given to group A (n = 8); simvastatin (10 mg/daily) was given to group B, for 1 year. All patients were examined at baseline, and monitored for safety during the study by pediatricians. All patients were submitted to noninvasive cardiovascular examinations (exercise electrocardiogram, echocardiography). After 12 months of treatment with simvastatin, total cholesterol (TC) and low density lipoprotein cholesterol (LDLC) showed a statistically significant reduction (group B). The decrease of TC and LDLC in patients on diet only was 4% and 3% (all) and 17% and 4% (group A) after 6 and 12 months, respectively.

Treatment of homozygous and double heterozygous familial hypercholesterolemic children with LDL-apheresis.

Within the framework of a seven-year clinical experience on treatment of severe hyperlipoproteinemia with/without associated coronary heart disease, with therapeutic plasmapheresis (APO B-100-containing lipoprotein-apheresis), we focused the present report on two young patients aged 7 and 11 years, respectively. The older patient is a boy treated since 1990 by plasma-exchange, cascade filtration-low density lipoprotein apheresis (LDL-apheresis), and dextrane sulphate-LDL apheresis. Over the treatment period the patient was submitted to three consecutive coronary angiographies. The second is a girl first submitted to a coronary angiography and then treated with dextrane sulphate-LDL apheresis. Up to now, a total of one-hundred therapeutic plasmaphereses have been performed. The interval of treatment was of fifteen days, and a volume of 2-3000 ml of plasma was processed at each session. The systems used were the following: DIDECO Vivacell BT 798-A, DIDECO Vivacell BT 798-A + BT 803, DIDECO BT 985 (Dideco, Mirandola, Italy), KANEKA MA-01 (Kanegafuchi, Osaka, Japan). Mean (SD) plasma apo B-100-containing major lipoprotein-LDL, Lp(a)-levels during treatment, are reported below: [table: see text] The treatment was very well tolerated. Rare, moderate hypotensive events occurred. Nevertheless, all procedures were regularly completed. A mild hypochromic anemia, regressed using drug treatment, was observed in the boy. Along with the improvement of plasma atherogenic profile, a regression of skin xanthomas and unchanged favourable coronary angiograms, were obtained in the above mentioned patient.

[First prenatal diagnosis of familial hypercholesterolemia by a molecular biology technic]. / La prima diagnosi prenatale di ipercolesterolemia familiare mediante tecniche di biologia molecolare.

The first prenatal diagnosis for exclusion of homozygous familial hypercholesterolemia by using the so called technique of Restriction Polymorphism Fragment Length (RFLP's) on chorial villus DNA, was performed. The test was used when the mother of a seven-year-old child with homozygous familial hypercholesterolemia, became pregnant. Previous examination of DNA of both parents and of one hypercholesterolemic child, showed a mutation of the gene encoding for the synthesis of LDL-receptor. The comparison between first degree relatives RFLP's and the chorial villus RFLP's, showed the absence of a previously recognized mutation in the foetus. After a normal pregnancy, the child was born and his plasma cholesterol was within the "normal" range.

Effect of L-carnitine on plasma lipoprotein fatty acids pattern in patients with primary hyperlipoproteinemia.

PURPOSE: To investigate the effect of L-carnitine (L-C) administration on plasma lipoprotein fatty acids pattern in patients with primary hyperlipoprotinemia. PATIENTS AND METHODS: The effect of L-C on plasma lipoprotein fatty acids pattern was investigated in 24 male and female hyperlipoproteinemic patients, aged 51.3 +/- 7.8 years (lipoprotein phenotypes: IIb and IV, WHO, 1970). After hypolipidemic diet (P, 22%; C, 48%; L, 30%; S, 10%; M, 10%; PV, 10%, cholesterol < 300 mg/d) lasting 30 days, L-C was given at a daily dosage of 1 g t.i.d. for 90 days. RESULTS: Plasma total polyunsaturated to saturated fatty acids ratio (8/5) showed a statistically significant increase after L-C (baseline: 0.74 +/- 0.2, vs 120 days: 0.84 +/- 0.2; p < or = 0.03). A statistically significant decrease of HDLs 16:0 (baseline: 28.1 +/- 4.2 vs 120 days: 26.4 +/- 3.7; p < or = 0.002), HDL3s 16:0 (baseline: 28.6 +/- 4.5 vs 120 days: 26.9 +/- 3.6; p < or = 0.001) and VLDLs 14:0 (baseline: 2.0 +/- 0.8 vs 120 days: 1.6 +/- 0.6; p < or = 0.02), specular to a statistically significant increase of VLDL's 18:2 (baseline: 21.9 +/- 5.1 vs 120 days: 24.3 +/- 4.9; p < or = 0.01), was also observed. Plasma levels of total cholesterol and LDL-cholesterol were reduced after one month. Plasma apolipoprotein AI and B levels were significantly increased after 30 and 60 days of treatment with L-C. CONCLUSIONS: A less atherogenic plasma lipoprotein fatty acids profile was observed after 120 days of combined treatment with diet and L-C.

[LDL-apheresis: current status]. / La LDL-Aferesi: stato attuale.

PURPOSE: State of the art of LDL-apheresis and treatment of severe familiar hypercholesterolemia. PATIENTS AND METHODS: Clinical experience of treatment with LDL-apheresis of pediatric and adult patients with familial hypercholesterolemia using the following techniques: D.A.L.I., H.E.L.P., D.S.C. RESULTS: The outcome of treatment with LDL-apheresis in young patients, using the most recently introduced techniques, is reported. We have submitted to LDL-apheresis 11 pediatric patients. The youngest is aged 3.5. LDL-apheresis is able at improving the metabolic impairment and halting the natural evolution of atherosclerotic disease and atherosclerotic complications. CONCLUSIONS: At present, LDL-apheresis is the most effective and safe therapeutic approach to the treatment of homozygous, heterozygous and double heterozygous familial hypercholesterolemia.

Pattern of red blood cells and platelets cholesterol and fatty acids in homozygous familial hypercholesterolemic patients treated with LDL-apheresis.

Two homozygous familial hypercholesterolemic patients were treated with dextran-sulfate cellulose LDL-apheresis (DSC-LDL/A). We evaluated qualitatively and quantitatively, red cell and platelets membrane cholesterol and fatty acids, before and after LDL-apheresis. Fatty acids and cholesterol of red blood cells and platelets were determined by gas-chromatographic technique. We failed to observe any quantitative or qualitative modification, as far as the youngest patient (MD) is concerned. Only in the oldest patient (SM), docosaesanoic acid (22:6) values, were significantly reduced by LDL-A on quantitative basis. In the same patient, also mirystic acid (14:0) values, were significantly decreased as determined by qualitative method. The above mentioned fatty acids were significantly changed in platelets on treatment with LDL-apheresis performed on weekly basis.

Treatment of symptomatic HyperLp(a)lipoproteinemia with LDL-apheresis: a multicentre study.

LDL-apheresis (LDLa) efficacy in the treatment of symptomatic HyperLp(a)lipoproteinemia -HyperLp(a)- has been studied in a multicentre trial. After 3.1+/-2.7 years of weekly and biweekly treatment, the data from 19 patients (males:12; females:7; aged 53.8+/-9.3 years; mean body mass index: 24.6+/-2.3 Kg/m²) were evaluated. Data were collected using the same questionnaire shared by 5 participating centres. A total of 2331 procedures were performed. A mean of 3593.7+/-800.3 ml of plasma or 8115.3+/-2150.1 ml of blood, depending upon the technique used (H.E.L.P., D.A.LI., Dextransulphate, Lipocollect 200), was regularly treated on average every 10.1+/-2.6 days. Baseline mean Lp(a) levels were 172.3+/-153.8 mg/dL. The mean pre-/post-apheresis Lp(a) levels decreased from 124.5+/-107.2 mg/dL (p<0.001 vs baseline) to 34.2+/-40.6 mg/dL (p<0.001 vs pre-). Baseline mean LDL-cholesterol (LDLC) levels were 152.3+/-74.6 mg/dL. The mean pre-/post-apheresis LDLC levels decreased from 130.4+/-61.1 mg/dL (p<0.004 vs baseline) to 41.2+/-25.1 mg/dL (p<0.001 vs pre-). The hypolipidemic drugs given to the patients during LDLa were: ezetimibe+simvastatin, atorvastatin, rosuvastatin, pravastatin, acipimox, and omega-3 fatty acids. 58% of the patients had arterial hypertension. Cigarette smokers were 5.3%. Alcohol intake was present in 21%. 52.6% were physically active. Patients with coronary artery disease (CAD) submitted to coronary catheterization before LDLa were 95%. In 5.5% (#1) CAD recurred despite treatment with LDLa. 79% were submitted to coronary revascularization before LDLa. CAD was: monovasal in 8 patients (42.1%), bivasal in 5 (26.4%), trivasal in 4 (21%), plurivasal in 2 (10.5%). In 94.5% of the sample the lesions were stable (< 0% deviation) over 3.1+/-2.7 years. 37% had both CAD and extra-coronary artery disease. This multicentre study confirmed that long-term treatment with LDLa was at least able to stabilize CAD in the majority of the individuals with symptomatic HyperLp(a).

DALI low-density lipoprotein apheresis in homozygous and heterozygous familial hypercholesterolemic patients using low-dose citrate anticoagulation.

The purpose of this study was to clarify the efficacy and safety of direct adsorption of lipoprotein low-density lipoprotein apheresis (DALI LDL apheresis) in patients with severe homozygous and heterozygous familial hypercholesterolemia who showed minor adverse effects during treatment with the usual DALI configuration (AC 1:20) through the use of a new system with low-dose citrate anticoagulation (AC 1:40) developed in order to minimize citrate-related adverse effects. Serum total cholesterol and LDL-cholesterol (LDL-C) showed a decrease of 57% to 61%, and 62% to 67%, respectively, in the 2 patients. Serum lipoprotein (a) (Lp[a]) was higher in the homozygous patient (Patient 1: MD) and within the normal range in the heterozygous patient (Patient 2: ES). In the former, Lp(a) was reduced by 52%. Serum high-density lipoprotein cholesterol (HDL-C) showed a statistically insignificant acute reduction: 15% to 19%. The observed reduction is mainly related to the well-known effect of hemodilution. The cardiovascular risk (total cholesterol/HDL-C) was reduced in both patients (46% to 54%) as expected. Serum triglycerides were reduced by 33% to 49%. The mean blood volume processed per session was 7,600 ml. Fifteen treatments for each patient have successfully been completed without the appearance of any clinically significant subjective and objective symptoms related to treatment with the new system.

Effect of oral and transdermal hormone replacement therapy on lipid profile and Lp(a) level in menopausal women with hypercholesterolemia.

OBJECTIVE: The aim of this randomized clinical study was to evaluate the hormonal replacement therapy (HRT) effect on plasma lipoproteins and Lp(a) profile in 42 menopausal women with primary hypercholesterolemia (total cholesterol > 240 mg/dL). SETTING: University clinic. PATIENTS AND METHODS: 42 hypercholesterolemic menopausal women were randomly assigned to the following groups; (1) transdermal estradiol, 50 micrograms + medroxyprogesterone 10 mg/day for days; (2) conjugated equine estrogens, 0.625 mg/day + medroxyprogesterone acetate 10 mg/day for 12 days; (3) no treatment. At baseline and after 3 and 6 months two blood samples were collected with a 24-hour interval in order to reduce intraindividual and laboratory variability. Serum total cholesterol, HDL cholesterol, triglycerides, LDL cholesterol, and Lp(a) were determined. RESULTS: Total cholesterol and LDL cholesterol significantly decreased after 6 months in both treated groups in comparison to untreated women; HDL cholesterol and triglycerides showed only minimal changes. HRT at the dosage utilized in the study did not seem influence the Lp(a) concentrations after 3 and 6 months. CONCLUSIONS: Both transdermal and oral estrogens at medium dosage have a favorable influence on total cholesterol and LDL-cholesterol level of hypercholesterolemic menopausal women, but Lp(a) remains resistant to manipulation.

Platelet Activation in Hypercholesterolemic Patients Submitted to Therapeutic Plasmapheresis. An Ultrastructural Study.

Therapeutic plasmapheresis has been recommended as the choice therapy in patients with familial hypercholesterolemia. Little is known about the effect of plasmapheresis on platelet behavior. By means of electron microscopy we have studied the platelet plasma membrane of 4 patients with familial hypercholesterolemia who were submitted to repeated plasmaphereses. After each procedure of plasmapheresis, at the 15th day, morphometrical studies revealed a statistically significant increase in the surface density of the Open Canalicular System, which is considered a marker of platelet activation. However, during 12 months of plasmapheresis, a significant mean decrease in the morphometric parameters was observed. On one hand, these results indicate the necessity to consider the blood hemocoagulatory state in the patient who has been submitted to the above mentioned treatment, since the variation of these parameters after the therapeutic procedure, in a short time, could be potentially harmful to the patient; on the other hand, these results indicate, for the first time, the ability of the procedure to improve platelet behavior after repeated treatments on long term basis.

A form of familial hypobetalipoproteinaemia not due to a mutation in the apolipoprotein B gene.

Familial hypobetalipoproteinaemia (FHBL) is a dominant disorder of lipoprotein metabolism characterized by levels of apolipoprotein B-carrying lipoproteins (VLDL, IDL and LDL) which are 50% of the normal levels in the heterozygotes and almost absent in the homozygotes. Several reports have recently shown that the underlying defect in FHBL involves different mutations in the apo B gene which lead to reduced levels of apo B mRNA or to the production of truncated forms of apo B having either a lower synthetic rate or a higher catabolic rate than normal apo B. We here present a three-generation family with several FHBL members in which the linkage analysis shows absence of co-segregation between apo B gene alleles and the hypocholesterolaemic phenotype. We conclude that a dominantly transmitted mutation in a gene other than that for apo B is responsible for the low plasma cholesterol levels.

LDL apheresis in a homozygous familial hypercholesterolemic child aged 4.5.

Preliminary experience with the efficacy and safety of dextran sulfate cellulose low-density lipoprotein (LDL) apheresis for the treatment of a 4.5-year-old girl with homozygous familial hypercholesterolemia and coronary artery disease is reported. The decrease of the most atherogenic apolipoprotein B-containing lipoproteins, low-density lipoprotein (LDL) and lipoprotein(a) (Lp [a]), were in the ranges of 63.1-68.7%, and 52.5-58.6%, respectively. The child tolerated LDL apheresis without any clinically significant complications. Therefore, she was submitted to a long-term program of treatment at intervals of 15 days. The experience suggests the possibility of an early beginning of extracorporeal treatment with LDL apheresis in children severely affected by homozygous or double heterozygous familial hypercholesterolemia.

Acute and long-term effects of low-density lipoprotein (LDL)-apheresis on oxidative damage to LDL and reducing capacity of erythrocytes in patients with severe familial hypercholesterolaemia.

Several studies have suggested that the oxidative modification of low-density lipoprotein (LDL) could play a key role in the early stages of atherosclerosis. The susceptibility of LDL to oxidation has been found to be greater in patients with coronary heart disease. Familial hypercholesterolaemia (FH) is a powerful clinical model in which to study the predictive role of LDL in atherogenesis. LDL-apheresis is a treatment that is able to decrease lipid levels in plasma. This study was aimed at investigating the reducing capacity of erythrocytes and the in vitro susceptibility to oxidation of LDL isolated from patients with homozygous, heterozygous and double-heterozygous FH, who were treated fortnightly with LDL-apheresis or left untreated. In 14 FH patients, at baseline and after a cycle of treatment, the susceptibility of LDL to oxidative modification was analysed by studying the kinetics of conjugate diene formation. Plasma hydroperoxides, polyunsaturated fatty acid content, LDL electrophoretic mobility on agarose, the titre of auto-antibodies against oxidized LDL and serum paraoxonase activity were also measured. Furthermore, in order to evaluate a potential relationship between LDL oxidation and redox status, erythrocyte GSH and ATP levels were determined in FH patients treated regularly or never treated previously by LDL-apheresis. Unlike in the control group, the oxidative status of LDL in all FH patients was modified by LDL-apheresis, as revealed by the higher negative charge and the increase in levels of hydroperoxides and antibodies against oxidized LDL in the plasma. Our findings suggest both an acute effect and a long-term effect of LDL-apheresis in FH patients treated with dextran sulphate cellulose apheresis. The acute effect of LDL-apheresis on the susceptibility to oxidation of plasma and LDL was demonstrated by significant decreases in plasma hydroperoxide content, total LDL concentration and polyunsaturated fatty acid content. The increased resistance of LDL to oxidation was shown by prolongation of the lag time (P<0.05) in samples after a single cycle of treatment. The long-term effect of LDL-apheresis was demonstrated by the comparable values for lag phases (obtained from the kinetics of conjugate diene formation) in patients under active treatment and controls. Compared with healthy controls and untreated patients, the erythrocyte GSH content was significantly higher (P

Low-density lipoprotein apheresis in a patient aged 3.5 years.

UNLABELLED: A 3.5 y-old girl carrying a severe mutation of the LDL-receptor gene known as "FH Pavia", affected by homozygous familial hypercholesterolaemia (FH), and at high risk of developing coronary artery atherosclerosis was treated with selective dextran sulphate cellulose (DSC) column low-density lipoprotein apheresis (LDL-a). This is the youngest patient ever treated with LDL-a. Plasma total cholesterol (982 mg/dl) and LDL-cholesterol (939 mg/dl) (T-Chol, LDL-Chol) levels at baseline showed a transient decrease: -13.4%, and -16.8%, respectively, after 9 mo of combined treatment with a diet, cholestyramine (max. 12 g/d) and atorvastatin (max. 30 mg/d). However, the drugs were discontinued because of intolerance and an increase in aminotransferases and creatine phosphokinase in the plasma. Moreover, after 9 mo of this therapy, the mean plasma T-Chol and LDL-Chol levels were still high (930 mg/dl and 869.5 mg/dl, respectively). Therefore, 9 consecutive treatments with LDL-a were carried out every 15 d (plasma volumes treated: 1000-1700 ml). Mean plasma T-Chol, LDL-Chol, triglycerides (TG), and Lp(a) decreased significantly: -75.5%, -77.2%, -67.5% and -50.8%, respectively. HDL-cholesterol (HDL-Chol) concentration was considerably decreased immediately after apheresis because of haemodilution (X: -45.1%). CONCLUSION: LDL-a treatment improved the plasma apo B 100-containing lipoproteins--LDL, Lp(a)--profile in a homozygote with a severe inherited disorder in which coronary artery atherosclerosis frequently has its clinical onset before 10 y of age. At the time of this report, no significant side effects had been observed.