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Jung Y, Nelson HA, Lin DMH. Use of therapeutic plasma exchange to remove lipoprotein X in a patient with vanishing bile duct syndrome presenting with cholestasis, pseudohyponatremia, and hypercholesterolemia: A case report and review of literature. J Clin Apher 2024; 39:e22105. [PMID: 38334173 DOI: 10.1002/jca.22105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Lipoprotein X (Lp-X) is an abnormal lipoprotein found in multiple disease conditions, including liver dysfunction and cholestasis. High Lp-X concentrations can interfere with some laboratory testing that may result in spurious results. The detection of Lp-X can be challenging, and there is currently a lack of consensus regarding the management of Lp-X other than treating the underlying disease. CASE PRESENTATION A 42-year-old female with Hodgkin's lymphoma treated with dexamethasone, high dose cytarabine and cisplatin and vanishing bile duct syndrome confirmed by liver biopsy presented with cholestasis, pseudohyponatremia (sodium, 113 mmol/L; reference range 136-146 mmL/L; serum osmolality, 303 mOsm/kg), and hypercholesterolemia (> 2800 mg/dL, reference range < 200 mg/dL). Lp-X was confirmed by lipoprotein electrophoresis (EP). Although she did not manifest any specific signs or symptoms, therapeutic plasma exchange (TPE) was initiated based on laboratory findings of extreme hypercholesterolemia, spuriously abnormal serum sodium, and HDL values, and the potential for short- and long-term sequelae such as hyperviscosity syndrome, xanthoma, and neuropathy. During the hospitalization, she was treated with four 1.0 plasma volume TPE over 6 days using 5% albumin for replacement fluid. After the first TPE, total cholesterol (TC) decreased to 383 mg/dL and sodium was measured at 131 mmol/L. The patient was transitioned into outpatient maintenance TPE to eliminate the potential of Lp-X reappearance while the underlying disease was treated. Serial follow-up laboratory testing with lipoprotein EP showed the disappearance of Lp-X after nine TPEs over a 10-week period. LITERATURE REVIEW There are seven and four case reports of Lp-X treated with TPE and lipoprotein apheresis (LA), respectively. While all previous case reports showed a reduction in TC levels, none had monitored the disappearance of Lp-X after completing a course of therapeutic apheresis. CONCLUSION Clinicians should have a heightened suspicion for the presence of abnormal Lp-X in patients with cholestasis, hypercholesterolemia, and pseudohyponatremia. Once Lp-X is confirmed by lipoprotein EP, TPE should be initiated to reduce TC level and remove abnormal Lp-X. Most LA techniques are not expected to be beneficial since Lp-X lacks apolipoprotein B. Therefore, we suggest that inpatient course of TPE be performed every other day until serum sodium, TC and HDL levels become normalized. Outpatient maintenance TPE may also be considered to keep Lp-X levels low while the underlying disease is treated. Serum sodium, TC, and HDL levels should be monitored while on maintenance TPE.
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Affiliation(s)
- Yujung Jung
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah Health, Salt Lake City, Utah, USA
- ARUP Institute for Clinical and Experimental Pathology®, Salt Lake City, Utah, USA
| | - David Ming-Hung Lin
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Bedi S, Garcia E, Jeyarajah EJ, Shalaurova I, Perez-Matos MC, Jiang ZG, Dullaart RPF, Matyus SP, Kirk WJ, Otvos JD, Davidson WS, Connelly MA. Characterization of LP-Z Lipoprotein Particles and Quantification in Subjects with Liver Disease Using a Newly Developed NMR-Based Assay. J Clin Med 2020; 9:jcm9092915. [PMID: 32927635 PMCID: PMC7564541 DOI: 10.3390/jcm9092915] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Lipoprotein particles with abnormal compositions, such as lipoprotein X (LP-X) and lipoprotein Z (LP-Z), have been described in cases of obstructive jaundice and cholestasis. The study objectives were to: (1) develop an NMR-based assay for quantification of plasma/serum LP-Z particles, (2) evaluate the assay performance, (3) isolate LP-Z particles and characterize them by lipidomic and proteomic analysis, and (4) quantify LP-Z in subjects with various liver diseases. Methods: Assay performance was assessed for linearity, sensitivity, and precision. Mass spectroscopy was used to characterize the protein and lipid content of isolated LP-Z particles. Results: The assay showed good linearity and precision (2.5–6.3%). Lipid analyses revealed that LP-Z particles exhibit lower cholesteryl esters and higher free cholesterol, bile acids, acylcarnitines, diacylglycerides, dihexosylceramides, lysophosphatidylcholines, phosphatidylcholines, triacylglycerides, and fatty acids than low-density lipoprotein (LDL) particles. A proteomic analysis revealed that LP-Z have one copy of apolipoprotein B per particle such as LDL, but less apolipoprotein (apo)A-I, apoC3, apoA-IV and apoC2 and more complement C3. LP-Z were not detected in healthy volunteers or subjects with primary biliary cholangitis, primary sclerosing cholangitis, autoimmune hepatitis, or type 2 diabetes. LP-Z were detected in some, but not all, subjects with hypertriglyceridemia, and were high in some subjects with alcoholic liver disease. Conclusions: LP-Z differ significantly in their lipid and protein content from LDL. Further studies are needed to fully understand the pathophysiological reason for the enhanced presence of LP-Z particles in patients with cholestasis and alcoholic liver disease.
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Affiliation(s)
- Shimpi Bedi
- Center for Lipid and Arteriosclerosis Science, Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH 45237-0507, USA; (S.B.); (W.S.D.)
| | - Erwin Garcia
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - Elias J. Jeyarajah
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - Irina Shalaurova
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - Maria Camila Perez-Matos
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (M.C.P.-M.); (Z.G.J.)
| | - Z. Gordon Jiang
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (M.C.P.-M.); (Z.G.J.)
| | - Robin P. F. Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, 9713 Groningen, The Netherlands;
| | - Steven P. Matyus
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - William J. Kirk
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - James D. Otvos
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
| | - W. Sean Davidson
- Center for Lipid and Arteriosclerosis Science, Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH 45237-0507, USA; (S.B.); (W.S.D.)
| | - Margery A. Connelly
- Laboratory Corporation of America Holdings (LabCorp), Burlington, NC 27560, USA; (E.G.); (E.J.J.); (I.S.); (S.P.M.); (W.J.K.); (J.D.O.)
- Correspondence: ; Tel.: +1-919-388-5534
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Vaisman BL, Neufeld EB, Freeman LA, Gordon SM, Sampson ML, Pryor M, Hillman E, Axley MJ, Karathanasis SK, Remaley AT. LCAT Enzyme Replacement Therapy Reduces LpX and Improves Kidney Function in a Mouse Model of Familial LCAT Deficiency. J Pharmacol Exp Ther 2018; 368:423-434. [PMID: 30563940 DOI: 10.1124/jpet.118.251876] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/26/2018] [Indexed: 12/14/2022] Open
Abstract
Familial LCAT deficiency (FLD) is due to mutations in lecithin:cholesterol acyltransferase (LCAT), a plasma enzyme that esterifies cholesterol on lipoproteins. FLD is associated with markedly reduced levels of plasma high-density lipoprotein and cholesteryl ester and the formation of a nephrotoxic lipoprotein called LpX. We used a mouse model in which the LCAT gene is deleted and a truncated version of the SREBP1a gene is expressed in the liver under the control of a protein-rich/carbohydrate-low (PRCL) diet-regulated PEPCK promoter. This mouse was found to form abundant amounts of LpX in the plasma and was used to determine whether treatment with recombinant human LCAT (rhLCAT) could prevent LpX formation and renal injury. After 9 days on the PRCL diet, plasma total and free cholesterol, as well as phospholipids, increased 6.1 ± 0.6-, 9.6 ± 0.9-, and 6.7 ± 0.7-fold, respectively, and liver cholesterol and triglyceride concentrations increased 1.7 ± 0.4- and 2.8 ±0.9-fold, respectively, compared with chow-fed animals. Transmission electron microscopy revealed robust accumulation of lipid droplets in hepatocytes and the appearance of multilamellar LpX particles in liver sinusoids and bile canaliculi. In the kidney, LpX was found in glomerular endothelial cells, podocytes, the glomerular basement membrane, and the mesangium. The urine albumin/creatinine ratio increased 30-fold on the PRCL diet compared with chow-fed controls. Treatment of these mice with intravenous rhLCAT restored the normal lipoprotein profile, eliminated LpX in plasma and kidneys, and markedly decreased proteinuria. The combined results suggest that rhLCAT infusion could be an effective therapy for the prevention of renal disease in patients with FLD.
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Affiliation(s)
- Boris L Vaisman
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Edward B Neufeld
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Lita A Freeman
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Scott M Gordon
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Maureen L Sampson
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Milton Pryor
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Emily Hillman
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Milton J Axley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Sotirios K Karathanasis
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
| | - Alan T Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (B.L.V., E.B.N., L.A.F., S.M.G., M.L.S., M.P., E.H., A.T.R.) and MedImmune, Gaithersburg, Maryland (M.J.A., S.K.K.)
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