Retrospective Analysis of Long-term Lipid Apheresis at a Single Center

Long-term lipoprotein apheresis reduces cardiovascular events in high-risk patients with isolated lipoprotein(a) elevation

BACKGROUND

Elevated lipoprotein(a) (Lp(a)) is an established risk factor for cardiovascular disease (CVD). To date, the only approved treatment to lower Lp(a) is lipoprotein apheresis (LA). Previous studies have demonstrated that LA is effective in reducing cardiovascular (CV) risk in patients with elevated low-density lipoprotein cholesterol (LDL-C) and/or Lp(a). Here we report our long-term experience with LA and its effectiveness in reducing CVD events in patients with elevated Lp(a).

METHODS

This retrospective open-label, single-center study included 25 individuals with Lp(a) elevation >60 mg/dL and LDL-C < 2.59 mmol/L who had indication for LA. The primary endpoint of this study was the incidence of any CV event (determined by medical records) after initiation of LA.

RESULTS

Mean LA treatment duration was 7.1 years (min-max: 1-19 years). Median Lp(a) was reduced from 95.0 to 31.1 mg/dL after LA (-67.3 %, p < 0.0001). Mean LDL-C was reduced from 1.85 to 0.76 mmol/L after LA (-58.9 %, p < 0.0001). Prior LA, 81 CV events occurred in total (0.87 events/patient/year). During LA, 49 CV events occurred in total (0.24 events/patient/year; -0.63, p = 0.001). Yearly major adverse cardiac event (MACE) rate was reduced from 0.34 to 0.006 (-0.33, p = 0.0002). Similar results were obtained when considering only individuals with baseline LDL-C below 1.42 mmol/L.

CONCLUSION

In this observational study of a heterogeneous CV high-risk cohort with elevated Lp(a), LA reduced Lp(a) levels and was paralleled by a decrease in CV events and MACE. We recommend LA for patients with high Lp(a) who still have CV events despite optimal lipid-lowering medication and lifestyle changes.

Clinical impact of a novel lipoprotein apheresis treatment on no-option chronic limb-threatening ischemia: Result from the REDUCTION VISCOSITY study

INTRODUCTION

Lipoprotein apheresis (LA) is a possible adjunct treatment for no-option chronic limb-threatening ischemia (CLTI). This study aimed to assess the impact of a novel LA for no-option CLTI.

METHODS

We retrospectively assessed 19 patients with no-option CLTI treated using the novel LA. The primary outcome was a change in the skin perfusion pressure (SPP) after treatment with LA, and the secondary outcomes were changes in the viscosity-related laboratory parameters.

RESULTS

The wound-healing rate was 68.4%. The SPP at 2-3 weeks after series of LA were significantly higher both in the dorsal (41 vs. 53 mmHg, p = 0.037) and plantar (50.0 vs. 61.0 mmHg, p = 0.018) sides, compared to those at baseline. The viscosity-related laboratory markers were also significantly improved after the treatment; low-density lipoprotein-cholesterol (57.0 vs. 43.0 mg/dL, p = 0.002), fibrinogen (333 vs. 258 mg/dL, p < 0.001), and C-reactive protein (0.99 vs. 0.42 mg/dL, p = 0.001).

CONCLUSION

The novel LA significantly increased the SPP and improved relevant laboratory findings.

Physiological role of plasma and its components and the clinical implications of different methods of apheresis: A narrative review

Nowadays, therapeutic plasmapheresis (TP) is accepted as part of the treatment for specific groups of diseases. The availability of different methods, including double filtration and adsorption, increases selectivity for the removal of substances. However, the use of these techniques requires a thorough understanding of the characteristics and components of plasma. By considering pivotal papers from several databases, the aim of this narrative review is to describe the characteristics of plasma related to apheresis techniques. We have tried to cover the clinical implications including physiology, estimation of plasma volume, viscosity, and a description of its components including the size, volume of distribution, and half-lives of the different substances to be removed or maintained depending on the clinical situation and applied apheresis technique. Applying this knowledge will help us to choose the right method and dosage and improve the efficacy of the procedure by preventing or addressing any complications.

Lipoprotein (a) and Low-density lipoprotein apolipoprotein B metabolism following apheresis in patients with elevated lipoprotein(a) and coronary artery disease

BACKGROUND

Lipoprotein apheresis effectively lowers lipoprotein(a) [Lp(a)] and low-density lipoprotein (LDL) by approximately 60%-70%. The rebound of LDL and Lp(a) particle concentrations following lipoprotein apheresis allows the determination of fractional catabolic rate (FCR) and hence production rate (PR) during non-steady state conditions. We aimed to investigate the kinetics of Lp(a) and LDL apolipoprotein B-100 (apoB) particles in patients with elevated Lp(a) and coronary artery disease undergoing regular apheresis.

PATIENTS AND METHODS

A cross-sectional study was carried out in 13 patients with elevated Lp(a) concentration (>500 mg/L) and coronary artery disease. Lp(a) and LDL-apoB metabolic parameters, including FCR and PR were derived by the fit of a compartment model to the Lp(a) and LDL-apoB concentration data following lipoprotein apheresis.

RESULTS

The FCR of Lp(a) was significantly lower than that of LDL-apoB (0.39 [0.31, 0.49] vs 0.57 [0.46, 0.71] pools/day, P = 0.03) with no significant differences in the corresponding PR (14.80 [11.34, 19.32] vs 15.73 [11.93, 20.75] mg/kg/day, P = 0.80). No significant associations were observed between the FCR and PR of Lp(a) and LDL-apoB.

CONCLUSIONS

In patients with elevated Lp(a), the fractional catabolism of Lp(a) is slower than that of LDL-apoB particles, implying that different metabolic pathways are involved in the catabolism of these lipoproteins. These findings have implications for new therapies for lowering apolipoprotein(a) and apoB to prevent atherosclerotic cardiovascular disease.

Long-term lipoprotein apheresis in the treatment of severe familial hypercholesterolemia refractory to high intensity statin therapy: Three year experience at a lipoprotein apheresis centre

BACKGROUND

Severe familial hypercholesterolemia (FH) individuals, refractory to conventional lipidlowering medications are at exceptionally high risk of cardiovascular events. The established therapeutic option of last choice is lipoprotein apheresis (LA). Herein, it was sought to investigate the clinical usefulness of LA in a highly selected group of severe heterozygous FH (HeFH), as recently described by the International Atherosclerosis Society (IAS), for their efficacy in lipid reduction and safety.

METHODS

Efficacy and safety of LA were investigated in 318 sessions of 7 severe HeFH females with cardiovascular disease, over a mean period of 26.9 ± 6.5 months. Relative reduction of low density lipoprotein cholesterol (LDL-C) ≥ 60%, clinical complications and vascular access problems were evaluated and compared between the direct adsorption of lipoproteins (DALI) and lipoprotein filtration (Membrane Filtration Optimized Novel Extracorporeal Treatment [MONET]). Additionally, lipoprotein (a) [Lp(a)], total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglycerides (TG) and fibrinogen concentrations were investigated.

RESULTS

The relative reduction of LDL-C, TC, TG and Lp(a) were 69.4 ± 12.9%, 59.7 ± 9.1, 51.5 ± ± 14.2% and 71.3 ± 14.4%, respectively. A similar efficacy was found in both systems in LDL-C removal. DALI system led to larger depletions of Lp(a) (80.0 [76-83]% vs. 73.0 [64.7-78.8]%; p < 0.001). The frequency of clinical side effects and vascular access problems were low (8.5%).

CONCLUSIONS

Long-term LA in severe HeFH individuals is safe and efficiently reduces LDL-C and Lp(a). Higher efficacy of the DALI system than MONET in Lp(a) removal may indicate the need for individualized application of the LA system in severe HeFH individuals.

Apheresis to Mitigate Atherosclerotic Vascular Disease

BACKGROUND

Therapeutic apheresis is a term used to describe a group of treatments where blood components are separated in real time, and one component is removed, exchanged, and/or treated to remove pathogenic substances from the circulation. Plasma exchange, which removed all plasma components, and lipid apheresis which selectively removes lipoproteins from circulation, have both been used to treat atherosclerotic vascular diseases.

METHODS

To review the literature regarding the application of therapeutic apheresis for atherosclerotic vascular diseases.

RESULTS

Primarily lipid apheresis is used to treat atherosclerotic vascular diseases, particularly familial hypercholesterolemia, lipoprotein (a) hyperlipoproteinemia and peripheral vascular diseases. Lipid apheresis can be used as first line or second line treatment with a strong evidenced-based recommendation. Its use has decreased atherosclerotic events.

CONCLUSION

Lipid apheresis is an important therapy for the treatment of familial hypercholesterolemia, lipoprotein (a) hyperlipoproteinemia and peripheral vascular diseases. Lipid apheresis does more than remove low-density lipoproteins and other lipoproteins but also decreases inflammatory markers and improves blood flow.

Lipoprotein apheresis in the management of severe hypercholesterolemia and of elevation of lipoprotein(a): current perspectives and patient selection

This review reports the current situation with respect to therapeutic options (lifestyle and drugs) reducing the concentrations of atherogenic low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp[a]). Three lipoprotein apheresis (LA) principles have been realized: precipitation, filtration, and adsorption. Available LA methods are herein described in detail - major components, pumps, extracorporeal volume, treated volume, and anticoagulation. General features of all LA methods as well as pleotropic effects are elaborated. Indications for LA therapy are quoted: homozygous familial hypercholesterolemia (HCH), severe HCH, and isolated elevation of Lp(a) and progress of atherosclerotic disease. A major focus is on the evidence of the effect of LA on cardiovascular outcome data, and the most important publications are cited in this context. The best studies have been performed in patients with elevated Lp(a) in whom cardiovascular events were reduced by more than 80%. Major adverse effects and contraindications are listed. The impact of an LA therapy on patient quality of life and the requirements they have to fulfill are also highlighted. Finally, the future role of LA in treating high-risk patients with high LDL-C and/or high Lp(a) is discussed. It is probable that the significance of LA for treating patients with elevated LDL-C will decrease (with the exception of homozygous familial HCH) due to the application of PCSK9 inhibitors. The antisense oligonucleotide against apolipoprotein(a) could replace LA in patients with high Lp(a), provided positive outcome data are generated.

Lipoprotein apheresis for the treatment of elevated circulating levels of lipoprotein(a): a critical literature review

Lipoprotein(a), which consists of a low-density lipoprotein (LDL) particle linked to an apolipoprotein(a) moiety, is currently considered an independent risk factor for cardiovascular disease due to its atherogenic (LDL-like) and prothrombotic (plasminogen-like) properties. The aim of this review is to provide an overview of the current and newer therapies for lowering increased lipoprotein(a) levels, focusing on lipoprotein apheresis. After a systematic literature search, we identified ten studies which, overall, documented that lipoprotein apheresis is effective in reducing increased lipoprotein(a) levels and cardiovascular events.

Lipoprotein(a) apheresis

PURPOSE OF REVIEW

Currently, different methods for extracorporeal elimination of atherogenic apolipoprotein B100 containing lipoprotein particles are used in clinical practice. Most of them effectively remove both lipoprotein(a) [Lp(a)] and LDL. The aim of this review is to highlight research describing the clinical advantages of specific Lp(a) immunosorption compared with other lipoprotein apheresis systems.

RECENT FINDINGS

Data on the utility of lipoprotein apheresis in patients with elevated Lp(a) level are limited. However, several longitudinal studies demonstrated improvement in cardiovascular outcomes when both Lp(a) and LDL cholesterol levels were decreased with different apheresis systems. The main limitation of these trials is the absence of a control group. First developed in 1991, studies on apheresis with a specific immunosorbent to Lp(a) were small and noncontrolled before 2000s. The only prospective controlled clinical trial utilising Lp(a) apheresis (Clinicaltrials.gov NCT02133807), demonstrated regression of coronary and carotid atherosclerosis when Lp(a) was removed weekly for 18 months.

SUMMARY

Lipoprotein apheresis usually affects multiple lipoproteins, and there are minimal data regarding the effect of specific removal of Lp(a) alone. There is a need for randomized controlled trial with specific Lp(a) apheresis to investigate its effect on cardiovascular outcomes.

Homozygous autosomal dominant hypercholesterolaemia: prevalence, diagnosis, and current and future treatment perspectives

PURPOSE OF REVIEW

Homozygous autosomal dominant hypercholesterolemia (hoADH) is a rare genetic disorder caused by mutations in LDL receptor, apolipoprotein B, and/or proprotein convertase subtilisin-kexin type 9. Both the genetic mutations and the clinical phenotype vary largely among individual patients, but patients with hoADH are typically characterized by extremely elevated LDL-cholesterol (LDL-C) levels, and a very high-risk for premature cardiovascular disease. Current lipid-lowering therapies include bile acid sequestrants, statins, and ezetimibe. To further decrease LDL-C levels in hoADH, lipoprotein apheresis is recommended, but this therapy is not available in all countries.

RECENT FINDINGS

Recently, the microsomal triglyceride transfer protein inhibitor lomitapide and the RNA antisense inhibitor of apolipoprotein B mipomersen were approved by the Food and Drug Administration/European Medicine Agency and the Food and Drug Administration, respectively. Several other LDL-C-lowering strategies and therapeutics targeting the HDL-C pathway are currently in the clinical stage of development.

SUMMARY

Novel therapies have been introduced for LDL-C-lowering and innovative drug candidates for HDL-C modulation for the treatment of hoADH. Here, we review the current available literature on the prevalence, diagnosis, and therapeutic strategies for hoADH.

Lipoprotein apheresis and new therapies for severe familial hypercholesterolemia in adults and children

Familial hypercholesterolemia (FH), the most common and severe monogenic form of hypercholesterolemia, is an autosomal co-dominant disease characterized by an increased plasma low density lipoprotein (LDL)-cholesterol concentration and premature coronary heart disease (CHD). The clinical phenotype depends on the gene involved and severity of mutation (or mutations) present. Patients with homozygous or compound heterozygous FH have severe hypercholesterolemia (LDL-cholesterol >13 mmol/L) due to a gene dosing effect and without treatment have accelerated atherosclerotic CHD from birth, and frequently die of CHD before age 30. Cholesterol-lowering therapies have been shown to reduce both mortality and major adverse cardiovascular events in individuals with FH. Lipoprotein apheresis concomitant with lipid-lowering therapy is the treatment of choice for homozygous FH. This article describes the rationale and role of lipoprotein apheresis in the treatment of severe FH and outlines the recent advances in new pharmacotherapies for this condition.

Pediatric therapeutic apheresis: rationale and indications for plasmapheresis, cytapheresis, extracorporeal photopheresis, and LDL apheresis

Apheresis refers to the removal of a component of the blood and is performed using a group of medical technologies in which peripheral blood is processed by an instrument that separates the various components. The selected component is isolated while the remainder is returned to the patient. The rationale behind therapeutic apheresis is to remove the pathogenic components from the circulation. Apheresis is also used for peripheral hematopoietic progenitor cell collection. The procedure can be safely performed in most children with modifications to account for smaller pediatric blood volumes.

The evidence-base for the efficacy of lipoprotein apheresis in combating cardiovascular disease

OBJECTIVE

To review the evidence supporting the use of lipoprotein apheresis to treat severe forms of dyslipidaemia that predispose to cardiovascular disease and are refractory to conventional therapy.

METHODS

Review of relevant publications based on personal knowledge and a search of the literature from the past 10 years using PubMed.

RESULTS

There is good evidence that drastic lowering of LDL by lipoprotein apheresis increases longevity in homozygous familial hypercholesterolaemia (FH) and decreases cardiovascular morbidity in FH heterozygotes refractory to or intolerant of statins. Lipoprotein apheresis may also decrease cardiovascular events in patients with raised levels of Lp(a) but further data are needed.

CONCLUSIONS

Lipoprotein apheresis currently provides a therapeutic life-line for a small number of very high risk patients. It remains to be seen what effect the recent emergence of several novel and powerful lipid-lowering drugs will have on its future role in that respect.

Differences in the atherogenic risk of patients treated by lipoprotein apheresis according to their lipid pattern

In high-risk patients who are already on a maximal lipid-lowering therapy, a lipoprotein apheresis is an important therapeutic option in preventing further progress of vascular complications as it may decrease both LDL-cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) levels. We looked at the occurrence of cardiovascular events before apheresis and during apheresis in three groups defined by their lipid patterns at the start of an apheresis treatment: Group 1 (LDL-C ≥ 3.4 mmol/l and Lp(a) ≤ 600 mg/l; n = 35), Group 2 (LDL-C ≤ 3.4 mmol/l and Lp(a) ≥ 600 mg/l n = 37) and Group 3 (LDL-C ≥ 3.4 mmol/l and Lp(a) ≥ 600 mg/l; n = 15). Group 2 shows a time period of about 10 years from the first event until the start of apheresis treatment (compared to 2-6 years in the other two groups). Before the start of apheresis treatment 2.1 events per patient had occurred in Group 1, 3.4 events per patient in Group 2 and 1.8 events per patient in Group 3. Under apheresis therapy just 0.9 events per patient occurred in Group 1, 0.5 in Group 2 and 0.5 in Group 3. When comparing the two years before the start of apheresis treatment with the first two years under apheresis we saw the following reduction rates of cardiovascular events: Group 1-54%; Group 2-83%; Group 3-83.5%. Our results show that the reduction of cardiovascular events due to lipoprotein apheresis is especially high in patients with elevated levels of Lp(a) compared to patients with elevated LDL-C only indicating that physicians should be more focused on the risk factor elevated Lp(a).

Lipoprotein apheresis of hypercholesterolemic patients mediates vasoprotective gene expression in human endothelial cells

OBJECTIVE

Hypercholesterolemia is an important risk factor of cardiovascular diseases. Lipoprotein apheresis is an efficient strategy to reduce the serum low-density lipoprotein (LDL)-cholesterol and lipoprotein(a) levels and cardiovascular complications in patients with severe hypercholesterolemia. The underlying molecular mechanisms are not well-understood. In this study, we analyzed the impact of lipoprotein apheresis on gene expression in human endothelial cells.

METHODS

Human endothelial cells were stimulated with serum of hypercholesterolemic patients before and after lipoprotein apheresis. The expression of endothelial lipoprotein receptors, nitric oxide (NO) synthase and adhesion molecules was quantified by real-time PCR and Western blot.

RESULTS

Lipoprotein apheresis reduced the expression of the lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) in endothelial cells. Low-density lipoprotein (LDL) receptor expression remained unchanged. The mRNA expression of the endothelial nitric oxide synthase (eNOS) was increased with serum of hypercholesterolemic patients after lipoprotein apheresis. In contrast, endothelial expression of vascular cell adhesion molecule 1 (VCAM-1) was reduced in response to serum after lipoprotein apheresis.

CONCLUSION

Lipoprotein apheresis reduced the expression of the proatherosclerotic oxLDL receptor LOX-1 and adhesion molecule VCAM-1 and increased the expression of vasoprotective and NO generating eNOS in human endothelial cells in response to serum of hypercholesterolemic patients. These novel molecular mechanisms may account for the antiatherosclerotic and vasoprotective potential of lipoprotein apheresis in patients with hypercholesterolemia.

Complement profile and activation mechanisms by different LDL apheresis systems

Extracorporeal removal of low-density lipoprotein (LDL) cholesterol by means of selective LDL apheresis is indicated in otherwise uncontrolled familial hypercholesterolemia. During blood-biomaterial interaction other constituents than the LDL particles are affected, including the complement system. We set up an ex vivo model in which human whole blood was passed through an LDL apheresis system with one of three different apheresis columns: whole blood adsorption, plasma adsorption and plasma filtration. The concentrations of complement activation products revealed distinctly different patterns of activation and adsorption by the different systems. Evaluated as the final common terminal complement complex (TCC) the whole blood system was inert, in contrast to the plasma systems, which generated substantial and equal amounts of TCC. Initial classical pathway activation was revealed equally for both plasma systems as increases in the C1rs-C1inh complex and C4d. Alternative pathway activation (Bb) was most pronounced for the plasma adsorption system. Although the anaphylatoxins (C3a and C5a) were equally generated by the two plasma separation systems, they were efficiently adsorbed to the plasma adsorption column before the "outlet", whereas they were left free in the plasma in the filtration system. Consequently, during blood-biomaterial interaction in LDL apheresis the complement system is modulated in different manners depending on the device composition.

Defining the role of lipoprotein apheresis in the management of familial hypercholesterolemia

Familial hypercholesterolemia (FH) is an autosomal co-dominant disorder characterized by a marked elevation of serum low-density lipoprotein (LDL) cholesterol (LDL-C) concentration, which in turn is associated with a greatly increased risk of premature cardiovascular disease. International consensus recommends the use of statins as the first line of treatment for patients with this condition. However, homozygote FH patients with persistently elevated LDL-C levels are usually resistant to multiple-drug therapy. Fortunately, LDL apheresis (or simply 'lipoprotein apheresis') provides a treatment option for patients who are refractory or intolerant to lipid-lowering medications, or if there is progressive cardiovascular disease despite maximal drug therapy. Lipoprotein apheresis is an extracorporeal LDL-C-lowering treatment similar in concept to renal dialysis. There are now five main methods for extracorporeal lipoprotein apheresis in use, namely dextran sulfate adsorption (DSA), heparin extracorporeal LDL precipitation (HELP), polyacrylate full blood adsorption (PFBA or DALI® system) using hemoperfusion, immunoadsorption, and filtration plasmapheresis. Lipoprotein apheresis has been shown to be successful in reducing LDL-C levels, as well as levels of lipoprotein(a) [Lp(a)], a prothrombotic proatherogenic lipoprotein. In contrast, however, lipoprotein apheresis seems to have a smaller effect in preventing atherosclerosis progression, thus suggesting that a major component of the reduction in cardiovascular events may be mediated by mitigating Lp(a) levels. Side effects are infrequent and mild, and have mainly consisted of lightheadedness, nausea, vomiting, and hypotension. As these are often bradykinin-mediated and associated with concomitant ACE inhibitor use, angiotensin type 2 receptor antagonists should be used instead of ACE inhibitors with DALI and PFBA. Nevertheless, there is scope for wider application of lipoprotein apheresis. The high cost and invasive nature of lipoprotein apheresis limits uptake; however, it is an important treatment modality that should be considered in carefully selected patients. National and international registries compiling outcome data for lipoprotein apheresis need to be established to help expand the evidence base regarding its effectiveness.

Low-density lipoprotein apheresis: principles and indications

Low-density lipoprotein (LDL) apheresis describes a group of apheresis techniques that selectively remove apolipoprotein B-containing lipoproteins producing an acute reduction in LDL-cholesterol (LDL-C). Six devices are available for the removal of LDL-C while sparing other important plasma components. The LDL-apheresis (LDL-A) is not routinely used for the treatment of hypercholesterolemia, which usually responds to medical management, but is used to treat familial hypercholesterolemia, an inherited metabolic abnormality resulting in premature death due to progressive coronary artery disease, and to treat patients who fail medical management. The mechanism of action of the available LDL-A devices, reactions that can occur with these treatments, and the role of this specialized apheresis technique in the treatment of hypercholesterolemia are described.

Changes in Lipids and Lipoproteins after Selective LDL Apheresis (7-Year Experience)

Background. The aim of the study was to investigate the changes in plasma lipids and lipoproteins and the cardiovascular events after selective LDL apheresis. Methods and Results. Two pediatric patients with familial hypercholesterolemia aged 11 and 13 years and 19 dyslipidemic adults aged 41 ± 14 years underwent direct adsorption of lipoproteins (DALI) sessions. The mean follow-up period was 47 ± 23 months. The total cholesterol (TC) values before and after treatment were 8.2 ± 2.2 and 3.1 ± 1.6 mmol/l (318 ± 86 and 122 ± 62 mg/dL), respectively. The interval mean of TC was 6.9 ± 1.9 mmol/l (268 ± 75 mg/dL). The LDL cholesterol concentrations before and after treatment were 6.6 ± 2.1 and 1.7 ± 1.1 mmol/l, (256 ± 82 mg/dL and 65 ± 41 mg/dL), respectively. The percentage of acute LDL cholesterol reduction was 75 ± 11%. Cardiovascular events were observed in seven patients. The average annual event rate was 5.51%. Conclusion. LDL apheresis is a very important therapeutic tool in managing patients at high risk for premature CAD or with aggressive CAD, despite adequate medical treatment.

Lipoprotein apheresis

PURPOSE OF REVIEW

Lipoprotein apheresis is being performed with increasing frequency, but better data collection and recording of clinical outcomes are needed. Setting up registries would facilitate this process.

RECENT FINDINGS

This review appraises recent articles that discuss the need for national registries and requirements for setting them up, the efficacy of lipoprotein apheresis in homozygous familial hypercholesterolaemia and patients with coronary disease secondary to raised levels of lipoprotein (a), and its role in the management of acute pancreatitis secondary to severe hypertriglyceridaemia.

SUMMARY

Lipoprotein apheresis seems to be going through a growth spurt, presumably reflecting better implementation of treatment guidelines or a broadening of indications for its use.