Direct adsorption of lipoproteins from whole blood by DALI apheresis: technique and effects

Extracorporeal LDL-Cholesterol Elimination in the Treatment of Severe Familial Hypercholesterolemia

The extracorporeal elimination of LDL-cholesterol could be performed using the classic non-selective centrifuge or membrane plasmapheresis. The modern methods are more selective and effective. The atherogenic particules are removed from plasma by active colon or capsula. The methods include: cascade filtration, imunoadsorbtion, heparin-induced precipitation of LDL, thermofiltration, dextran-induced precipitation of LDL and direct adsorption of lipids (DALI). The regular LDL-apheresis is the life-saving technique in the treatment of homozygous familial hypercholesterolaemia. It is used in heterozygous familial hypercholesterolaemia when the patients do not respond to diet and drugs therapy, too. The regular LDL-apheresis treatment may be followed by the decreased frequency of angina pain episodes, the reduction of ECG changes during the bicycle ergometry and significant disappearance of tendinous xantomas. Some prospective randomised studies has shown even in this group of patients, resistant to conventional treatment, a significant regression of atherosclerotic changes.

Retrospective Comparison of 5 different Methods for Long-Term LDL-Apheresis in 20 Patients between 1986 and 2001

Purpose

To compare long-term efficacy and biocompatibility of the 5 most commonly applied LDL-apheresis techniques using a specifically modified calculation method of the area under the curve (AUC) for laboratory parameters.

Design

Retrospective long-term analysis of 20 patients with homozygous or severe heterozygous familial hypercholesterolemia.

Procedures

The following 5 extra-corporeal LDL-apheresis methods were compared: IMAL (Immuno Adsorption of Lipoproteins), DSA (Dextran Sulphate Adsorption), HELP (Heparin Induced Extra-corporeal LDL Precipitation), DALI (Direct Adsorption of Lipoproteins), MDF (Membrane Differential Filtration).

Main outcome measures

AUC derived plasma concentrations (CAUC) of lipoproteins between two apheresis procedures and their long-term course. Comparison of biocompatibility and efficacy concerning the LDL-C target of < 2.6 mmol/L of 5 apheresis techniques. Progression of atherosclerosis in patients with severe hypercholesterolemia.

Main findings

The means of AUC derived average plasma concentrations (CAUC) of all treatment intervals were for LDL-C and the LDL/HDL ratio as follows: IMAL (5.59 mmol/L; ratio 4.1), DSA (3.03 mmol/L; ratio 2.0), HELP (4.06 mmol/L; ratio 2.2), DALI (3.83 mmol/L; ratio 3.3), MDF (3.26 mmol/L; ratio 3.2). Coronary heart disease and cardiac events (myocardial infarction, PTCA/ stent implantation, CABG) progressed in only 2 patients whereas atherosclerosis manifestations (sclerosis abdominal aorta, carotid artery stenosis, peripheral vascular disease) worsened in 13 patients. Mean ergometric capacity improved from 112 to 118 Watt.

Conclusions

All 5 apheresis methods (IMAL, DSA, HELP, DALI, MDF) proved to be safe and suitable for long-term treatment in patients with severe hypercholesterolemia. The introduction of the CAUC revealed that the target of LDL-C < 2.6 mmol/L was not achieved with regard to the time averaged concentration (CAUC).

Long-term follow-up of circulating oxidative stress markers in patients undergoing lipoprotein apheresis by Direct Adsorption of Lipids (DALI)

OBJECTIVE

Beyond its well-established efficacy in lowering atherogenic lipids and lipoproteins, DALI (Direct Adsorption of Lipids) apheresis has been shown to have acute anti-inflammatory and endothelium-protective effects. In the present study, we investigated long-term effects of DALI procedures on circulating oxidative stress markers.

METHODS

Thirteen patients involved in the study underwent regular DALI apheresis for nearly two years. At sessions 1, 40 and 80 conventional lipid status and changes of systemic oxidative stress markers (oxidized LDL, anti-oxidized LDL antibodies, advanced oxidation protein products (AOPP), and myeloperoxidase (MPO)) were examined.

RESULTS

DALI procedure efficiently reduced atherogenic lipids/lipoproteins. On day three after apheresis lipid parameters returned to pre-apheresis values. They showed no tendency to increase or to decrease over time. No significant differences were found between 1st, 40th and 80th sessions. In a similar way, levels of oxidative stress biomarkers acutely decreased after apheresis sessions and rebounded on day three after apheresis. No significant differences were observed between sessions 1, 40, and 80.

CONCLUSION

DALI apheresis repeatedly decreases atherogenic lipid/lipoprotein profile and oxidative stress biomarker levels during each session. Among all investigated parameters no longitudinal effects over two years could be observed.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Severe/Extreme Hypertriglyceridemia and LDL Apheretic Treatment: Review of the Literature, Original Findings

Hypertriglyceridemia (HTG) is a feature of numerous metabolic disorders including dyslipidemias, metabolic syndrome, and diabetes mellitus type 2 and can increase the risk of premature coronary artery disease. HTG may also be due to genetic factors (called primary HTG) and particularly the severe/extreme HTG (SEHTG), which is a usually rare genetic disorder. Even rarer are secondary cases of SEHTG caused by autoimmune disease. This review considers the causes of SEHTG, and their management including treatment with low density lipoprotein apheresis and analyzes the original findings.

New Ligand Coupling Procedure for Formation of an Immunoadsorption Wall

To prevent the occurrence of dialysis-related amyloidosis, an immunoadsorption wall based on polyacrylamide has been manufactured by a recently developed, partially incomplete, two-stage polymerization method. During the preparation process, efficient utilization of coupling antibodies is the key to large-scale production of such a toxin removal modality. In this study, we attempted to carry out the ligand coupling procedure after formation of a cyanogen bromide (CNBr)-activated stationary phase, using anti-beta2-microglobulin (beta-2M) antibodies. In vitro immunoadsorption tests show that the levels of beta-2M decrease rapidly within the first 2 hours for all the immunoadsorption tests. After that, nearly blank values were reached for tests of initial levels of c. 30 microg/mL and c. 82 microg/mL, whereas a relatively constant level of c. 10 microg/mL was maintained for the test of initial levels of c. 185 microg/mL. The maximum surface binding capacity of the prepared immunoadsorption walls is estimated by fitting experimental data, using a mathematical model of saturation kinetics. The present comparative investigation also suggests the manufacturing process for an immunoadsorption wall could be improved and facilitated by this new ligand coupling procedure without compromising the resulting binding capacity. Furthermore, the experimental protocols as well as the present methodology could be helpful for development of a clinically applicable immunoadsorption wall.

Low-density Lipoprotein Apheresis Therapy With a Direct Hemoperfusion Column: A Japanese Multicenter Clinical Trial

Low-density lipoprotein (LDL) apheresis has been applied to patients with familial hypercholesterolemia (FH) with coronary artery disease (CAD). To examine the efficacy and safety of a new type of LDL adsorption column (KLD01, Kaneka, Osaka, Japan), which deals with whole blood without separating plasma, the new system was evaluated in a multicenter trial. The present study included 33 FH patients with CAD (24 males, 9 females, 57 +/- 13 years) who were treated five times with a mean interval of 2.12 +/- 0.60 weeks between treatments. We studied the removal efficacies for serum LDL cholesterol, Lipoprotein(a) (Lp(a)) and triglyceride, the times for the preparation of the system and for treatment, symptoms, and the biochemical data. The scheduled treatments were completed by 31 patients. Serum levels of LDL cholesterol, Lp(a) and triglycerides were all significantly reduced with KLD01; 61.5 +/- 6.2%, 72.4 +/- 5.9% and 69.5 +/- 9.7%, respectively. The times for both setting up the column system (26 +/- 7 min) and treatment (138 +/- 20 min) were shorter with KLD01 than conventional methods. Adverse reactions occurred in eight cases (17 episodes), but the patients fully recovered immediately after each apheresis therapy session. We conclude that the new type of LDL adsorption column, one that deals with whole blood, is a promising apheresis therapy for FH patients in view of its efficacy, reduced time for treatment, and safety.

Direct Adsorption of Lipoproteins from Whole Blood by Direct Adsorption of Lipoprotein Apheresis: First Experience in Two Hypercholesterolemic Children

Low density lipoprotein (LDL) cholesterol apheresis, combined with lipid lowering drugs, provides a safe and effective means of improving the prognosis of patients with homozygote familial hypercholesterolemia, especially if started before the age of seven. The direct adsorption of lipoprotein (DALI) is the first extracorporeal low density lipoprotein removing system compatible with whole blood. The purpose of the present study was to clarify the efficacy and safety of DALI in children with homozygous familial hypercholesterolemia. Two boys, aged 9 and 15 years, with familial hypercholesterolemia, who were highly resistant to dietary regimes and to drug therapy, were treated with the low density lipoprotein adsorber DALI apheresis once every 2 weeks for 24 weeks. The treated blood volumes for each procedure were 2911 mL (493 +/- SD) and 5982 mL (1129 +/- SD), respectively. In our patients, the acute mean LDL cholesterol reductions were 44.7 +/- 8.9% and 58.8 +/- 4.5%. The corresponding reductions were 42.5 +/- 7.2% and 56 +/- 4.3% for total cholesterol, and 46.5 +/- 17.1% and 55 +/- 7.5% for very low density lipoprotein cholesterol (VLDL-C). There were insignificant losses of high density lipoprotein (12.2 +/- 5.7%, 8.3 +/- 5.5%). Treatment was well tolerated in general, and neither patient suffered from irreversible or long-lasting adverse effects. Our experience with DALI apheresis is encouraging. The present report is the first on the use of DALI in children. Based on this short-term evaluation we think that DALI might be safe and effective in children with homozygote familial hypercholesterolemia, however further evaluation of long-term effects is needed.

LDL Apheresis: an effective and safe treatment for refractory hypercholesterolemia

Through the efforts of Edward H. Ahrens, LDL apheresis became available for the treatment of patients, often with familial hypercholesterolemia, who have no alternative therapy for severely elevated LDL cholesterol levels. In the U.S., the FDA has approved this treatment for individuals on maximum diet and drugs with an LDL cholesterol greater than 300 mg/dL or greater than 200 mg/dL with coronary artery disease. Unlike plasmapheresis, apolipoprotein B-containing lipoproteins (LDL, Lp(a), and VLDL) are selectively removed by heparin precipitation or columns containing dextran sulfate cellulose or antibodies to apolipoprotein B. The acute lowering of LDL-cholesterol by a typical 2 - 3 h treatment is up to 80%, and the time-averaged lowering in the 1 to 2 week interval between treatments is up to 50%, with very few side effects. The lowering of LDL-cholesterol and other cardioprotective effects of LDL apheresis have reduced chest pain, prevented new disability and prolonged life. Whole blood compatible columns in development offer the possibility of simpler and less expensive treatments.

Modified DALI LDL-apheresis using trisodium citrate anticoagulation plus bicarbonate or lactate-buffered hemofiltration substitution fluids as primers

BACKGROUND

DALI (direct adsorption of lipids) is the first LDL-apheresis technique able to adsorb low-density lipoprotein (LDL) and lipoproteina) directly from whole blood. In the standard procedure, acid citrate dextrose (ACD-A) is used as anticoagulation and the adsorber is rinsed with a specially manufactured priming solution (PS). Using neutral trisodium citrate (TSC) instead of ACD-A might improve the acid-base homeostasis during DALI apheresis; moreover, applying wholesale hemofiltration solutions instead of the special PS might avoid the use of two separate solutions for both priming before and reinfusion after the treatment, thus simplifiying the procedure.

AIM

The present study was performed to test the effect of neutral (TSC) anticoagulation and of two different commercially available hemofiltration (HF) priming solutions on the efficacy and biocompatibility of DALI apheresis.

MATERIALS AND METHODS

Five hypercholesterolemic chronic DALI patients were treated prospectively, on a weekly or biweekly basis, 3 times each by standard DALI-apheresis (A). by DALI using 4% TSC and bicarbonate-buffered HF BIC35-210 priming (B). as well as by DALI using 4% TSC and lactate-buffered HF 23 priming (C). After the sessions, the extracorporeal circuit (ECC) was rinsed with saline in study arm A and with the corresponding HF solutions in study arms B and C, respectively.

RESULTS

Acute LDL-cholesterol reductions in the study arms A/B/C averaged 64/64/63%, for Lp(a) 62/64/62%, respectively (n=15). Clinically, all sessions were essentially uneventful and no clots were observed in the ECC. No major differences were found between the 3 study arms with respect to biocompatibility (elastase, C3a, thrombin-antithrombin, beta-thromboglobulin, bradykinin).

CONCLUSION

DALI apheresis using TSC anticoagulation and HF solutions for both priming and reinfusion proved to be as safe and effective as the standard DALI apheresis. These modifications, however, further simplify the procedure.

Micro- and macrocirculatory effects of apheresis in patients with familial hyperlipidemia

High lipid levels have been shown to coexist with a disturbed vascular endothelial function. Thus, acute lipid lowering could be expected to improve vascular reactivity. Patients with familial hyperlipidemia (FH) have substantial and rapid decreases in lipid levels after low-density lipoprotein apheresis. Thus, an opportunity exists to study acute effects of lipid lowering on vascular reactivity. Flow mediated vasodilation (FMD) is commonly used to assess endothelial function in conduit vessels, whereas vital capillary microscopy during the post-reactive hyperemia (PRH) phase is used to assess response at the microvascular level. It is not known whether endothelial dysfunction is a general phenomenon in all kinds of vessels or if there are differences between micro- and macrovessels. In the present study, we were not able to demonstrate an improved vascular response after acute lipid lowering in FH patients. This was true both in the microcirculation (PRH) and in the conduit vessels (FMD). However, the two methods gave concordant results, demonstrating disturbed vascular reactivity in the patients as compared with healthy subjects. We have found no previous report with parallel assessments at the microcirculatory and macrocirculatory levels.