Treatment of homozygous familial hypercholesterolemia with low density lipoprotein apheresis: a 4 year follow-up study

Effect of Lipoprotein Apheresis on Oxidative Stress and Antioxidant Status in Familial Hypercholesterolemic Patients

Extracorporeal low-density lipoprotein (LDL) apheresis is an established and highly effective therapy for the patients with familial hypercholesterolemia (FH) not adequately responding to diet and drug therapy alone. This study was designed to measure the effect of lipid apheresis on oxidant and antioxidant status in a patient with FH. The levels of plasma lipid peroxidation were determined as thiobarbituric acid-reactive substances. The activities of the antioxidant enzymes superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) were established in one subject with FH before and after lipid apheresis.

The pre- and post lipid apheresis procedures witness a significant decrease in oxidative stress (p<0.05) but the erythrocyte levels of CAT, SOD and GPx were unchanged.

Familial hypercholesterolemia--improving treatment and meeting guidelines

Familial hypercholesterolemia (FH) is a common, inherited disorder that affects around one in 500 individuals in the heterozygous form. By the year 2001, more people in the US had FH than were infected by the human immunodeficiency virus. The disease is caused by mutations within the low-density lipoprotein (LDL) receptor gene. FH is associated with elevated plasma LDL-cholesterol (LDL-C) levels, xanthomatosis, early onset of atherosclerosis and premature cardiac death. Patients with heterozygous FH commonly have plasma LDL-C levels that are two-fold higher than normal, while homozygotes have four- to five-fold elevations in plasma LDL-C. Although FH patients have a high risk of developing premature coronary heart disease (CHD), they remain underdiagnosed and undertreated. Early detection of FH is critical to prolonging the life of these patients. Once identified, patients with heterozygous FH can be placed on a diet and drug management program. As the most efficacious and well-tolerated agents, hydroxy methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are usually the drugs of first choice; bile acid sequestrants, niacin, and occasionally fibrates may be used as supplemental agents. Statins may also provide a realistic option for the treatment of some FH homozygotes with genes that produce partially functional LDL receptors. However, a number of patients are still failing to reach treatment guidelines even with the most effective of the currently available statins. The development of new more efficacious statins or the use of new combination therapies such as statins with the cholesterol absorption inhibitor, ezetimibe may help to reduce the current problem of undertreatment in FH patients.

Identification of complement activators and elucidation of the fate of complement activation products during extracorporeal plasma purification therapy

It has been known for many years that the complement system is activated during extracorporeal plasma purification (ECCP) therapy. In a previous study, we showed that high concentrations of complement activation products (CAPs) are returned to the patient during immunoadsorption treatment. In the present study, we investigated the question of where complement activation takes place with different forms of ECPP equipments as well as the fate of the CAPs. Eleven patients (8 men and 3 women), mean age 52 +/- 18 years, were included in the study. They were treated either with plasmapheresis (PP), immunoadsorption, bilirubin adsorption, or low density lipoprotein (LDL) apheresis. It was found that during all ECPP treatments and after the plasma separation filter, the plasma concentrations of CAPs were increased, and that high concentrations of CAPs were returned to the patients, except with PP. The plasma levels of individual CAPs varied between different types of ECPP. These variations were due to several factors: (1) complement activation (CA) on the plasma separator and a secondary device, e.g., column or membrane; (2) adsorption of specific CAPs to separation columns; and (3) reduction of CAPs due to separation and waste. Since CAPs have inflammatory and immunological effects, it is possible that high serum concentration of CAPs in the treated patients may influence the clinical outcome of the treatment. In conclusion, complement activation is a fact that should not be ignored during performance of any form of an ECPP. It is the plasma separator that plays a key role in the process of complement activation. Different ECPP treatments may have different effects regarding the levels of individual CAPs.

Therapeutic efficiency of lipoprotein(a) reduction by low-density lipoprotein immunoapheresis

This study was performed to investigate the effect of low-density lipoprotein (LDL) immunoapheresis on lipoprotein(a) [Lp(a)] reduction in patients with heterozygous and homozygous familial hyperlipidemia (N=16) and insufficient response to lipid-lowering agents. By desorption of approximately 5,700+/-500 mL of plasma, a mean reduction in total cholesterol of 62% (P < .001) and in LDL-cholesterol of 70% (P < .001) was achieved. Lp(a), which was elevated at study entry in seven of these patients (82.1+/-34.3 mg/dL; range, 48 to 148 mg/dL), was reduced during the initial LDL-apheresis procedure by 74.8%+/-14.1% (P < .001). Long-term apheresis treatment performed at weekly intervals resulted in an mean reduction in Lp(a) pretreatment values to 39.1+/-28.5 mg/dL (-54%; P < .001). Desorbed Lp(a) was measured at the waste of the columns for 31 apheresis treatments. Lp(a) concentration of the column waste was higher in patients with elevated serum Lp(a) pretreatment values as compared with those with Lp(a) serum values within the normal range (elevated Lp(a), 1,420+/-380 mg; without elevated Lp(a), 235+/-190 mg; P < .001). The rate of return of Lp(a) following apheresis treatment scheduled at weekly intervals was comparable to that of LDL-cholesterol.