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Rationale and study design of a clinical trial to assess the effects of LDL apheresis on proteinuria in diabetic patients with severe proteinuria and dyslipidemia. Clin Exp Nephrol 2017; 22:591-596. [PMID: 29080119 DOI: 10.1007/s10157-017-1488-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Diabetic nephropathy is a leading cause of end-stage kidney disease in the world. Although various types of treatment for diabetes, hypertension and dyslipidemia have improved prognosis and quality of life in patients with diabetic nephropathy, there still exist some diabetic patients with severe proteinuria showing poor prognosis. This clinical trial, LICENSE, aims to confirm the impact of LDL apheresis on proteinuria exhibiting hyporesponsiveness to treatment. METHODS This ongoing trial is a multicenter, prospective study of diabetic patients with severe proteinuria. The objective is to examine the impact of LDL apheresis on proteinuria in patients with diabetic nephropathy. The other subject is to investigate safety of LDL apheresis in these patients. RESULTS The subjects consist of diabetic patients with serum creatinine (Cr) levels below 2 mg/dL who present severe proteinuria above 3 g/g Cr or 3 g/day and LDL cholesterol above 120 mg/dL. The target number of registered patients will be 35 patients. Urinary protein excretion and renal function will be observed for 24 weeks after the treatment of LDL apheresis. CONCLUSION This study will determine the effectiveness and safety of LDL apheresis for diabetic nephropathy patients with severe proteinuria and dyslipidemia.
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Yabuuchi J, Suwabe T, Mizuno H, Ueno T, Hoshino J, Sekine A, Kawada M, Yamanouchi M, Hayami N, Hiramatsu R, Hasegawa E, Sawa N, Takaichi K, Fujii T, Ohashi K, Ubara Y. Long-term Low-density Lipoprotein Apheresis in a Patient with Refractory Idiopathic Membranous Glomerulonephritis. Intern Med 2017. [PMID: 28626181 PMCID: PMC5505911 DOI: 10.2169/internalmedicine.56.8081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 61-year-old Japanese man developed nephrotic syndrome (NS) due to idiopathic membranous glomerulonephritis (MGN). He received immunosuppressive therapy for two years, including prednisolone, cyclophosphamide, and cyclosporine A, but the NS persisted. Low-density lipoprotein apheresis (LDL-A) was initiated at a frequency of twice a month and continued for 9 years (203 sessions in total). His proteinuria reduced to less than 1 g daily after 9 years. LDL-A was stopped, and the NS has not relapsed for five years. This case suggests that long-term LDL-A therapy may be a treatment option for idiopathic MGN refractory to immunosuppressive therapy or short-term LDL-A.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Naoki Sawa
- Nephrology Center, Toranomon Hospital, Japan
| | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City University, Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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Muso E, Mune M, Hirano T, Hattori M, Kimura K, Watanabe T, Yokoyama H, Sato H, Uchida S, Wada T, Shoji T, Takemura T, Yuzawa Y, Ogahara S, Sugiyama S, Iino Y, Sakai S, Ogura Y, Yukawa S, Nishizawa Y, Yorioka N, Imai E, Matsuo S, Saito T. A Prospective Observational Survey on the Long-Term Effect of LDL Apheresis on Drug-Resistant Nephrotic Syndrome. NEPHRON EXTRA 2015; 5:58-66. [PMID: 26557843 PMCID: PMC4592509 DOI: 10.1159/000437338] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS LDL apheresis (LDL-A) is used for drug-resistant nephrotic syndrome (NS) as an alternative therapy to induce remission by improvement of hyperlipidemia. Several clinical studies have suggested the efficacy of LDL-A for refractory NS, but the level of evidence remains insufficient. A multicenter prospective study, POLARIS (Prospective Observational Survey on the Long-Term Effects of LDL Apheresis on Drug-Resistant Nephrotic Syndrome), was conducted to evaluate its clinical efficacy with high-level evidence. METHODS Patients with NS who showed resistance to primary medication for at least 4 weeks were prospectively recruited to the study and treated with LDL-A. The long-term outcome was evaluated based on the rate of remission of NS 2 years after treatment. Factors affecting the outcome were also examined. RESULTS A total of 58 refractory NS patients from 40 facilities were recruited and enrolled as subjects of the POLARIS study. Of the 44 subjects followed for 2 years, 21 (47.7%) showed remission of NS based on a urinary protein (UP) level <1.0 g/day. The UP level immediately after LDL-A and the rates of improvement of UP, serum albumin, serum creatinine, eGFR, and total and LDL cholesterol after the treatment session significantly affected the outcome. CONCLUSIONS Almost half of the cases of drug-resistant NS showed remission 2 years after LDL-A. Improvement of nephrotic parameters at termination of the LDL-A treatment was a predictor of a favorable outcome.
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Affiliation(s)
- Eri Muso
- Division of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Institute, Tokyo, Japan
| | | | - Tsutomu Hirano
- Department of Diabetes, Metabolism and Endocrinology, Tokyo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenjiro Kimura
- Department of Nephrology and Hypertension, Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Tsuyoshi Watanabe
- Department of Nephrology, Hypertension, Diabetology, Endocrinology and Metabolism, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Yokoyama
- Division of Nephrology, Kanazawa Medical University School of Medicine, Uchinada, Japan
| | - Hiroshi Sato
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takashi Wada
- Department of Laboratory Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Tetsuo Shoji
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Tokyo, Japan
| | - Tsukasa Takemura
- Department of Pediatrics, Kinki University School of Medicine, Osaka, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Satoru Ogahara
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka, Japan
| | | | - Yasuhiko Iino
- Department of Nephrology, Nippon Medical School, Tokyo, Japan
| | | | - Yousuke Ogura
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | | | - Yoshiki Nishizawa
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Tokyo, Japan
| | | | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Seiichi Matsuo
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takao Saito
- General Medical Research Center, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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4
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Applications of LDL-apheresis in nephrology. Clin Exp Nephrol 2008; 12:9-15. [PMID: 18175056 DOI: 10.1007/s10157-007-0003-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Accepted: 08/24/2007] [Indexed: 12/31/2022]
Abstract
LDL-apheresis (LA) was originally used for familial hyperlipidemia, and then in Japan extended to use for the treatment of patients with peripheral arterial disease (PAD) and nephrotic syndrome due to steroid-resistant focal glomerular sclerosis (FGS). The reason why this treatment is applicable for these disorders is due to the fact that LA exerts its favorable effects beyond the lipid-lowering effect. The main underlying mechanisms, for example, in the case of LA application in patients with PAD are: (1) improvement of hemorheology, (2) improvement of endothelial dysfunction, (3) elevations of serum levels of NO and bradykinin, (4) increase in serum levels of vascular endothelial growth factor, and (5) reduction of adhesion molecules on monocytes. Furthermore, we have reported that LA could have anti-inflammatory effects because LA reduces serum levels of P-selectin, which is known to play an important role in the development of atherosclerosis as well as a reduction of serum C-reactive protein levels as standard biomarker of atherosclerosis. Massive proteinuria is also an important challenge in nephrology. The possible mechanisms besides removal of toxic lipids are the reduction of the vasoconstrictive prostanoid and thromboxane A2 (TXA2) and an improvement in macrophage function evidenced by a significant amelioration of interleukin-8 production by lipopolysaccharide-stimulated peripheral blood mononuclear cells. It is intriguing to note that in terms of pharmacodynamics, LA improves steroid and cyclosporine uptake into lymphocytes. Although there are no randomized controlled trials, it is clear that LA has various effects beyond lowering lipids. Making the device more concise and changing it into a whole blood adsorption type, we need to collect more clinical cases and to study the underlying mechanisms further.
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Nakamura T, Kawagoe Y, Ogawa H, Ueda Y, Hara M, Shimada N, Ebihara I, Koide H. Effect of low-density lipoprotein apheresis on urinary protein and podocyte excretion in patients with nephrotic syndrome due to diabetic nephropathy. Am J Kidney Dis 2005; 45:48-53. [PMID: 15696443 DOI: 10.1053/j.ajkd.2004.09.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The aim of the present study is to determine whether low-density lipoprotein (LDL) apheresis affects proteinuria and urinary podocyte excretion in patients with type 2 diabetes and nephrotic syndrome. METHODS LDL apheresis was performed on patients with diabetes with long-standing nephrotic syndrome, and urinary protein level and number of urinary podocytes were compared between these patients (5 men, 3 women; mean age, 54.6 years) and 10 nephrotic patients with diabetes not treated with LDL apheresis (6 men, 4 women; mean age, 56.5 years). RESULTS LDL apheresis reduced total cholesterol (P < 0.001), LDL cholesterol ( P < 0.001), lipoprotein(a) (P < 0.001), creatinine (P < 0.05), and blood urea nitrogen (P < 0.05) levels and increased creatinine clearance (P < 0.05). The LDL apheresis group showed a significant decrease in urinary protein excretion (from 10.8 +/- 3.2 to 1.8 +/- 1.1 g/d; P < 0.001) and number of urinary podocytes (from 4.8 +/- 2.2 to 0.9 +/- 0.4 cells/mL; P < 0.01). CONCLUSION These data suggest that LDL apheresis effectively reduces proteinuria and podocyte excretion, ameliorating renal dysfunction in patients with nephrotic syndrome caused by diabetic nephropathy.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Medicine, Shinmatsudo Central General Hospital, Chiba, Japan
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Wang Z, Jiang T, Li J, Proctor G, McManaman JL, Lucia S, Chua S, Levi M. Regulation of renal lipid metabolism, lipid accumulation, and glomerulosclerosis in FVBdb/db mice with type 2 diabetes. Diabetes 2005; 54:2328-35. [PMID: 16046298 DOI: 10.2337/diabetes.54.8.2328] [Citation(s) in RCA: 234] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diabetic kidney disease has been associated with the presence of lipid deposits, but the mechanisms for the lipid accumulation have not been fully determined. In the present study, we found that db/db mice on the FVB genetic background with loss-of-function mutation of the leptin receptor (FVB-Lepr(db) mice or FVBdb/db) develop severe diabetic nephropathy, including glomerulosclerosis, tubulointerstitial fibrosis, increased expression of type IV collagen and fibronectin, and proteinuria, which is associated with increased renal mRNA abundance of transforming growth factor-beta, plasminogen activator inhibitor-1, and vascular endothelial growth factor. Electron microscopy demonstrates increases in glomerular basement membrane thickness and foot process (podocyte) length. We found that there is a marked increase in neutral lipid deposits in glomeruli and tubules by oil red O staining and biochemical analysis for cholesterol and triglycerides. We also detected a significant increase in the renal expression of adipocyte differentiation-related protein (adipophilin), a marker of cytoplasmic lipid droplets. We examined the expression of sterol regulatory element-binding protein (SREBP)-1 and -2, transcriptional factors that play an important role in the regulation of fatty acid, triglyceride, and cholesterol synthesis. We found significant increases in SREBP-1 and -2 protein levels in nuclear extracts from the kidneys of FVBdb/db mice, with increases in the mRNA abundance of acetyl-CoA carboxylase, fatty acid synthase, and 3-hydroxy-3-methylglutaryl-CoA reductase, which mediates the increase in renal triglyceride and cholesterol content. Our results indicate that in FVBdb/db mice, renal triglyceride and cholesterol accumulation is mediated by increased activity of SREBP-1 and -2. Based on our previous results with transgenic mice overexpressing SREBP-1 in the kidney, we propose that increased expression of SREBPs plays an important role in causing renal lipid accumulation, glomerulosclerosis, tubulointerstitial fibrosis, and proteinuria in mice with type 2 diabetes.
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Affiliation(s)
- Zhuowei Wang
- Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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Kamijo A, Kimura K, Sugaya T, Yamanouchi M, Hikawa A, Hirano N, Hirata Y, Goto A, Omata M. Urinary fatty acid-binding protein as a new clinical marker of the progression of chronic renal disease. ACTA ACUST UNITED AC 2004; 143:23-30. [PMID: 14749682 DOI: 10.1016/j.lab.2003.08.001] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Previous studies have indicated that in massive proteinuria, free fatty acids (FFAs) bound to albumin were overloaded in the proximal tubule and exacerbated tubulointerstitial damage. Liver-type fatty acid-binding protein (L-FABP) is an intracellular carrier protein of FFAs that is expressed in the proximal tubule of human kidney. We sought to evaluate urinary L-FABP as a clinical marker in chronic renal disease. Urinary L-FABP was measured in patients with nondiabetic chronic renal disease (n = 120) with the use of a newly established ELISA method. We then monitored these patients for 15 to 51 months. Clinical data were analyzed with multivariate analysis. Urinary L-FABP was correlated with urinary protein, urinary alpha(1)-microglobulin, and serum creatinine concentrations. Urinary L-FABP at the start of follow-up (F = 17.1, r =.36, P <.0001) was selected as a significant clinical factor correlated with the progression rate, defined as a slope of a reciprocal of serum creatinine over time. We next selected the patients with mild renal dysfunction (n = 35) from all 120 patients and divided them into 2 groups according to progression rate: the progression group (n = 22) and the nonprogression group (n = 13). Serum creatinine and urinary protein concentrations and blood pressure at the start of follow-up were higher in the progression group than in the nonprogression group, although we detected no significant difference between the 2 groups. Urinary L-FABP was significantly higher in the former group than in the latter (P <.05). The results showed that urinary L-FABP reflected the clinical prognosis of chronic renal disease. Urinary L-FABP may be a clinical marker that can help predict the progression of chronic glomerular disease.
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Affiliation(s)
- Atsuko Kamijo
- Second Department of Internal Medicine, University of Tokyo, Tokyo, Japan
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Tuttle KR, Anderson PW. A novel potential therapy for diabetic nephropathy and vascular complications: protein kinase C beta inhibition. Am J Kidney Dis 2003; 42:456-65. [PMID: 12955673 DOI: 10.1016/s0272-6386(03)00741-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Diabetic nephropathy is one of the most common microvascular complications of diabetes mellitus and the leading cause of end-stage renal disease in developed countries. Current treatment includes glycemic control, blood pressure control (with special emphasis on agents targeting the renin-angiotensin system), a low-protein (0.6 to 0.8 g/kg) diet, and the use of hypolipidemic agents. Although these therapeutic options may slow progression, the burden of disease remains large, and additional therapeutic agents are urgently needed. Ruboxistaurin (LY333531) mesylate is a bisindolylmaleimide that shows a high degree of specificity within the protein kinase C (PKC) gene family for inhibiting PKC beta isoforms. In animal models of diabetes, including the streptozotocin (STZ) rat, Lepr(db)/Lepr(db) mouse, and STZ-Ren 2 rat models, ruboxistaurin normalized glomerular hyperfiltration, decreased urinary albumin excretion, and reduced glomerular transforming growth factor-beta1 and extracellular matrix protein production. As a result, improvements were noted in mesangial expansion, glomerulosclerosis, tubulointerstitial fibrosis, and renal function. Other studies using less specific probes of PKC activity also have shown an important role for PKC in the development of diabetic nephropathy and a close relationship to pathways believed to be important in its pathogenesis. Inhibition of PKC beta, a common signaling molecule in diabetes-related renal and vascular injury, holds promise as a novel strategy to improve microvascular and macrovascular outcomes in diabetes. Such therapies are needed to reduce the occurrence of devastating diabetic complications.
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MESH Headings
- Animals
- Animals, Genetically Modified
- Diabetes Mellitus, Experimental/drug therapy
- Diabetic Angiopathies/drug therapy
- Diabetic Angiopathies/enzymology
- Diabetic Nephropathies/complications
- Diabetic Nephropathies/drug therapy
- Diabetic Nephropathies/enzymology
- Drug Evaluation, Preclinical
- Endothelium, Vascular/enzymology
- Endothelium, Vascular/physiopathology
- Enzyme Inhibitors/pharmacology
- Enzyme Inhibitors/therapeutic use
- Female
- Humans
- Indoles/pharmacology
- Indoles/therapeutic use
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/prevention & control
- Male
- Maleimides/pharmacology
- Maleimides/therapeutic use
- Mice
- Mice, Mutant Strains
- Protein Kinase C/antagonists & inhibitors
- Protein Kinase C beta
- Rats
- Rats, Sprague-Dawley
- Receptors, Cell Surface/genetics
- Receptors, Leptin
- Renin/genetics
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Affiliation(s)
- Katherine R Tuttle
- Heart Institute of Spokane, Research Department, Spokane, WA 99204-2340, USA.
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Abstract
Low density lipoprotein (LDL) apheresis provides a safe and effective means of treating patients with homozygous familial hypercholesterolaemia (FH). It also has a role in preventing the progression of coronary artery disease in heterozygotes and others with severe dyslipidaemia who are refractory to or intolerant of high doses of lipid-lowering drugs. Established methods involve either adsorption of apolipoprotein B-containing lipoproteins by affinity columns containing anti-apolipoprotein B antibodies or dextran sulphate, or their precipitation at low pH by heparin, in each instance after first separating plasma from blood cells with a cell separator. The most recently developed method enables lipoproteins to be adsorbed directly from whole blood, using polyacrylate columns. All 4 methods have proved to be similarly efficient when used weekly or biweekly to lower LDL cholesterol and Lp(a) without unduly reducing HDL cholesterol. Economic constraints restrict the use of LDL apheresis to the treatment of potentially fatal disorders such as FH, where there is clear evidence of benefit compared with conventional therapy. Widening the indications to include the treatment of other dyslipidaemic disorders such as steroid-resistant nephrotic syndrome, post-transplant donor vessel disease, stroke and prevention of re-stenosis after coronary angioplasty requires evidence from controlled trials that is currently lacking.
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Affiliation(s)
- Gilbert R Thompson
- Metabolic Medicine, Division of Investigative Sciences, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 ONN, United Kingdom.
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Vella A, Pineda AA, O'Brien T. Low-density lipoprotein apheresis for the treatment of refractory hyperlipidemia. Mayo Clin Proc 2001; 76:1039-46. [PMID: 11605688 DOI: 10.4065/76.10.1039] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The advent of treatment with 3-hydroxy-3-methylglutaryl coenzyme A inhibitors has meant that, with a combination of diet and drug therapy, adequate control of serum cholesterol concentrations can be achieved in most patients with hypercholesterolemia. However, some patients, primarily those with familial hypercholesterolemia (FH), may require additional therapy to lower their cholesterol levels. In recent years, low-density lipoprotein (LDL) apheresis has emerged as an effective method of treatment in these patients. The criteria for commencement of LDL apheresis are LDL cholesterol levels of 500 mg/dL or higher for homozygous FH patients, 300 mg/dL or higher for heterozygous FH patients in whom medical therapy has failed, and 200 mg/dL or higher for heterozygous FH patients with documented coronary disease and in whom medical therapy has failed. In addition to cholesterol lowering in patients with FH, other indications for LDL apheresis are emerging. These include its use in the treatment of graft vascular disease in patients receiving cardiac transplants as well as in the treatment of certain glomerulonephritides. This review examines the role of LDL apheresis in the management of lipid disorders and the evidence available to support its use in clinical practice.
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Affiliation(s)
- A Vella
- Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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Moriarty PM, Gibson CA. Low-density lipoprotein apheresis in the treatment of atherosclerosis and other potential uses. Curr Atheroscler Rep 2001; 3:156-62. [PMID: 11177660 DOI: 10.1007/s11883-001-0052-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review concerns the clinical impact of low-density lipoprotein (LDL) apheresis for patients with refractory hypercholesterolemia. We examine and provide examples of investigations that have demonstrated the clinical benefits of LDL apheresis. In addition to benefits derived from the stabilization or regression of arterial lesions, we highlight other possible mechanisms related to clinical improvement. We also discuss the potential advantages of lipid apheresis for the treatment of patient populations other than those characterized by severe hypercholesterolemia and premature coronary heart disease.
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Affiliation(s)
- P M Moriarty
- Lipid, Atherosclerosis, and Metabolic Clinic, University of Kansas Medical Center, 1336 KU Hospital, 3901 Rainbow Boulevard, Kansas City, KS 66160-7374, USA.
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