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Elali I, Phachu D, Coombs N, Shah M, Dean J, Haider L, Wang Y, Kaplan AA. Membrane-based therapeutic plasma exchange: Proposed techniques for preventing filter failure. J Clin Apher 2023; 38:555-561. [PMID: 37287385 DOI: 10.1002/jca.22065] [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: 03/04/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Therapeutic plasma exchange (TPE) is commonly performed using membrane-based TPE (mTPE) and is prone to filter failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We report on 46 patients, with a total of 321 mTPE treatments using the NxStage machine. This was a retrospective study with an aim to evaluate the effect of heparin, pre-filter saline dilution and the impact of total plasma volume exchanged (< 3 L vs. ≥3 L) on the rate of filter failure. Primary outcome was the overall rate of filter failure. Secondary outcomes included factors that may have indirectly influenced the rate of filter failure, including hematocrit, platelet count, replacement fluid (Fresh Frozen Plasma vs. albumin), and access type. RESULTS We found that treatments that received both pre-filter heparin and saline had a statistically significant decrease in filter failure rate as compared to those that received neither (28.6% vs. 5.3%, P = .001), and compared to the treatments that received pre-filter heparin alone (14.2% vs. 5.3%, P = .015). In treatments that received both pre-filter heparin and saline predilution, we noted a significantly higher filter failure rate when the plasma volume exchanged was ≥3 L as compared to those that had <3 L exchanged (12.2% vs. 0.9%, P = .001). CONCLUSIONS Rate of filter failure in mTPE can be reduced by implementing several therapeutic interventions including pre-filter heparin and pre-filter saline solution. These interventions were not associated with any clinically significant adverse events. Despite the above-mentioned interventions, large plasma volume exchanges of ≥3 L can negatively impact filter life.
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Affiliation(s)
- Ibrahim Elali
- UConn Health, Department of Medicine, Division of Nephrology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Deep Phachu
- UConn Health, Department of Medicine, Division of Nephrology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Nick Coombs
- UConn Health, Department of Medicine, Division of Nephrology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mamta Shah
- UConn Health, Department of Medicine, Division of Nephrology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jordan Dean
- Division of Nephrology/Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lalarukh Haider
- UConn Health, Department of Medicine, Division of Nephrology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Yanlin Wang
- Division of Nephrology/Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Andre A Kaplan
- Division of Nephrology/Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Ledowsky CJ, Schloss J, Steel A. Variations in folate prescriptions for patients with the MTHFR genetic polymorphisms: A case series study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 10:100277. [PMID: 37228355 PMCID: PMC10205484 DOI: 10.1016/j.rcsop.2023.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 03/16/2023] [Accepted: 04/30/2023] [Indexed: 05/27/2023] Open
Abstract
Background Over 48.5 million couples are reported with infertility worldwide. Health policy recommends folic acid in women of childbearing age, particularly in preconception and pregnancy which results in women purchasing over-the-counter prenatal multivitamins containing folic acid through pharmacies and other retail outlets. Emerging studies are investigating whether other forms of supplemental folate are more suitable, particularly for those with methylenetetrahydrofolate reductase (MTHFR) polymorphisms. This case series aimed to document variations in forms and dosage of folate prescribed by Australian practitioners to patients with diagnosed infertility and MTHFR polymorphisms. Methods Australian practitioners were invited to complete a retrospective case report form for patients that presented with unexplained infertility. This case report form documented the form and dose of folate that practitioners were prescribing to their infertility patient with MTHFR polymorphisms, together with their fertility history. Results Six practitioners submitted case information for 12 patients with diagnosed infertility and MTHFR polymorphisms. All patients had been advised by their practitioner to remove folic acid in supplemental form and were prescribed 5-methyltetrahydrofolate (5-MTHF) or a combination of 5-MTHF and folinic acid, at higher doses than the Australian recommended dose (mean daily maximum prescribed dose: 2325μg). Eleven patients conceived within the treatment period (average treatment of one year) and ten were reported as having a live birth. Conclusion This case series has highlighted clinical practices that vary from the recommendations by Australian policy. Further research is required to verify the clinical importance of variations in folate prescriptions for women with MTHFR polymorphisms and how folate recommendations may need to change depending on these polymorphisms. This has direct relevance to those prescribing at the pharmacy and retail level, specifically pharmacists and pharmacy assistants.
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Affiliation(s)
- Carolyn Jane Ledowsky
- Endeavour College of Natural Health, now at University of Technology Sydney, Faculty of Health, Australia
| | - Janet Schloss
- Southern Cross University, Natural Centre for Naturopathic Medicine, Lismore, NSW, Australia
| | - Amie Steel
- University of Technology Sydney, Faculty of Health, Australia
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Abstract
PURPOSE OF REVIEW Lipoprotein apheresis has been first line therapy for homozygous familial hypercholesterolaemia (FH) and other severe and refractory forms of dyslpidaemia for over 40 years but the recent advent of novel and potent LDL-lowering compounds necessitates a reappraisal of its role. RECENT FINDINGS During the past decade a substantial amount of evidence has accumulated describing the effect of LDL-lowering with apheresis and conventional drug therapy upon the cardiovascular outcomes associated with homozygous and statin-refractory heterozygous FH. This has necessitated re-defining the target levels of LDL cholesterol needed to arrest progression of atherosclerosis in these situations. At the same time, evidence has accrued regarding the pathogenicity of raised levels of lipoprotein (a) and the promising role of apheresis in mitigating the adverse effects of the latter. The latest advance in treatment has been the introduction of three classes of novel and potent LDL-lowering compounds in the shape of inhibitors of Propertin convertase subtilisin kexin 9 (PCSK9), microsomal triglyceride transfer protein and angiopoietin-like 3. SUMMARY These recent developments raise the question of whether these compounds will be used as adjuvants to bolster lipoprotein apheresis in FH homozygotes or whether they will render it obsolete, as is already occurring with PCSK9 inhibitors in FH heterozygotes.
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Affiliation(s)
- Gilbert R Thompson
- Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London, United Kingdom
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Thompson GR. The scientific basis and future of lipoprotein apheresis. Ther Apher Dial 2021; 26:32-36. [PMID: 34331508 DOI: 10.1111/1744-9987.13716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 01/27/2023]
Abstract
Lipoprotein apheresis plays a vital role in the management of the severe hyperlipidemias that predispose to atherosclerosis. Determinants of efficacy are the acute reduction in lipoproteins achieved by each apheresis procedure, their frequency, and the fractional catabolic rates and hence pool sizes of low-density lipoprotein (LDL) or lipoprotein (a) (Lp(a)) of the patient being treated. A useful criterion of the efficacy of apheresis plus lipid-lowering drug therapy is the decrease in the interval (time-averaged) mean of serum total or LDL cholesterol or Lp(a) between procedures, expressed as the percent decrease in the interval means below the maximal levels of these lipoproteins when off all treatment. Recent advances in lipid-lowering drug therapy may diminish the use of lipoprotein apheresis but will not abolish its unique role as a therapeutic "last chance saloon," especially for children and pregnant women with homozygous familial hypercholesterolemia.
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Affiliation(s)
- Gilbert R Thompson
- Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
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Cohen H, Stefanutti C. Current Approach to the Diagnosis and Treatment of Heterozygote and Homozygous FH Children and Adolescents. Curr Atheroscler Rep 2021; 23:30. [PMID: 33963467 PMCID: PMC8105241 DOI: 10.1007/s11883-021-00926-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
Purpose of Review To elucidate the current approach of care in pediatric patients with familial hypercholesterolemia (FH). We sought an answer to the question whether the advances and major changes in lipid management are relevant and apply to children and adolescents. Recent Findings Latest research findings clearly demonstrate that lowering cholesterol levels at a young age prevents vascular atherosclerotic changes and decreases cardiovascular events in adulthood and emphasizes the importance of early detection and intervention in the pediatric FH patients group. Summary FH is a common genetic disease caused by mutations in genes associated with the metabolism of low-density lipoproteins (LDL). The hallmark of FH is elevated LDL cholesterol (LDL-C) levels from birth and premature atherosclerotic cardiovascular disease (ASCVD). Often FH is either undiagnosed or diagnosed with a considerable delay, leading to vascular atherosclerotic changes and cardiovascular disease. Prompt identification of FH subjects is essential, to initiate early preventive measures. Safe and efficient pharmacological agents are approved for use in children and adolescents. Statins are the first line of therapy, in combination of ezetimibe. Unfortunately, these drugs do not warrant the achievement of therapeutic target, especially in HoFH patient. In the latter, lipoprotein apheresis (LA), which has been shown to be safe and effective, is strongly recommended. Finally, the new drugs still under study will allow a multimodal customized treatment. Lowering cholesterol levels at a young age hinders vascular atherosclerotic changes decreasing cardiovascular events in adulthood. Therefore, early detection, diagnosis, and intervention in FH patients are priority objectives.
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Affiliation(s)
- Hofit Cohen
- The Bert W. Strassburger Lipid Center, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Stefanutti
- Department of Molecular Medicine, Lipid Clinic and Atherosclerosis Prevention Centre, Immunohematology and Transfusion Medicine, Regional Centre for Rare Diseases, Extracorporeal Therapeutic Techniques Unit – Severe Genetic Dyslipidemias, Umberto I Hospital, ‘Sapienza’ University of Rome, Rome, Italy
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6
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Abstract
PURPOSE OF REVIEW Lipoprotein apheresis is the most effective means of lipid-lowering therapy. However, it's a semi-invasive, time consuming, and chronic therapy with variable adherence. There are still no specific guideline recommendations for the management of patients on lipid apheresis. The purpose of this review is to discuss the clinical indications and major drawbacks of lipid apheresis in the light of recent evidence. RECENT FINDINGS Lipoprotein apheresis should be initiated at early ages and performed frequently to receive the expected cardiovascular benefits. However, in clinical practice, most patients experience ineffective apheresis and fail to reach lipid targets. This real-world failure is due to several factors including late diagnosis, delayed referral, and improper frequency of procedures. All these denote that awareness is still low among physicians. Another important factor is the semi-invasive, time consuming nature of the apheresis, leading to high refusal and low adherence rates. Moreover, apheresis decreases quality of life and increases the risk of depression. Mental status is also deteriorated in patients with familial hypercholesterolemia on lipid apheresis. New effective lipid lowering agents are underway with promising cardiovascular results. To overcome the drawbacks, a structured approach, including standardized protocols for lipoprotein apheresis with regular cardiovascular follow-up is warranted. New effective lipid lowering agents with documented cardiovascular benefit, should be integrated into the treatment algorithms of patients on lipoprotein apheresis.
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Affiliation(s)
- Meral Kayikcioglu
- Department of Cardiology, Faculty of Medicine, Ege University, İzmir, Turkey.
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7
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Abstract
After training as a gastroenterologist in the UK, the author became interested in lipidology while he was a research fellow in the USA and switched careers after returning home. Together with Nick Myant, he introduced the use of plasma exchange to treat familial hypercholesterolemia (FH) homozygotes and undertook non-steady state studies of LDL kinetics, which showed that the fractional catabolic rate of LDL remained constant irrespective of pool size. Subsequent steady-state turnover studies showed that FH homozygotes had an almost complete lack of receptor-mediated LDL catabolism, providing in vivo confirmation of the Nobel Prize-winning discovery by Goldstein and Brown that LDL receptor dysfunction was the cause of FH. Further investigation of metabolic defects in FH revealed that a significant proportion of LDL in homozygotes and heterozygotes was produced directly via a VLDL-independent pathway. Management of heterozygous FH has been greatly facilitated by statins and proprotein convertase subtilisin/kexin type 9 inhibitors but remains dependent upon lipoprotein apheresis in homozygotes. In a recent analysis of a large cohort treated with a combination of lipid-lowering measures, survival was markedly enhanced in homozygotes in the lowest quartile of on-treatment serum cholesterol. Emerging therapies could further improve the prognosis of homozygous FH; whereas in heterozygotes, the current need is better detection.
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Affiliation(s)
- Gilbert R Thompson
- Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom.
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8
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Patel PN, Giugliano RP. Low-density lipoprotein cholesterol lowering therapy for the secondary prevention of atherosclerotic cardiovascular disease. Glob Cardiol Sci Pract 2020; 2020:e202039. [PMID: 33598499 PMCID: PMC7868100 DOI: 10.21542/gcsp.2020.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent and a major contributor to morbidity and mortality worldwide. Elevated blood cholesterol is a key driver of risk for atherosclerotic events, and patients with established ASCVD comprise a specific high-risk population in which low-density lipoprotein cholesterol (LDL-C) lowering therapy is strongly endorsed by multiple guidelines. An increasing number of medications across several pharmacologic classes are available today in clinical practice. Therefore, guidance on the appropriate use of these interventions is necessary for cost-effective solutions to managing residual atherothrombotic risk. In this review we summarize the key evidence supporting LDL-C lowering as described in the most recent 2018 multi-society Blood Cholesterol Guidelines, and provide a framework for optimizing LDL-C lowering therapy in secondary prevention populations.
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Affiliation(s)
- Parth N Patel
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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9
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Giammanco A, Cefalù AB, Noto D, Averna MR. Therapeutic Options for Homozygous Familial Hypercholesterolemia: The Role of Lomitapide. Curr Med Chem 2020; 27:3773-3783. [DOI: 10.2174/0929867326666190121120735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/25/2018] [Accepted: 12/28/2018] [Indexed: 11/22/2022]
Abstract
Background:Lomitapide (Juxtapid® in US and Lojuxta® in Europe) is the first developed inhibitor of the Microsomal Triglyceride Transfer Protein (MTP) approved as a novel drug for the management of Homozygous Familial Hypercholesterolemia (HoFH). It acts by binding directly and selectively to MTP thus decreasing the assembly and secretion of the apo-B containing lipoproteins both in the liver and in the intestine.Aims:The present review aims at summarizing the recent knowledge on lomitapide in the management of HoFH.Results:The efficacy and safety of lomitapide have been evaluated in several trials and it has been shown a reduction of the plasma levels of Low-Density Lipoprotein Cholesterol (LDL-C) by an average of more than 50%. Although the most common side effects are gastrointestinal and liver events, lomitapide presents generally with a good tolerability and satisfactory patients compliance. Recently, in Europe, to evaluate the long-term safety and efficacy of lomitapide, the LOWER registry (ClinicalTrials.gov Identifier: NCT02135705) has been established in order to acquire informations on HoFH lomitapidetreated patients from “real life” clinical practice.:Furthermore, the observation that lomitapide decreases triglyceride levels may be considered for patients affected by severe forms of hypertriglyceridemia who undergo recurrent episodes of pancreatitis and are poor responders to conventional treatment.Conclusion:Lomitapide represents an innovative and efficacious drug for the treatment of HoFH. Longterm safety data, treatment of pediatric and pregnant HoFH patients and management of severe hypertriglyceridemia still require further investigations.
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Affiliation(s)
- Antonina Giammanco
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.Mi.S), Policlinico “Paolo Giaccone”, Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Angelo B. Cefalù
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.Mi.S), Policlinico “Paolo Giaccone”, Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Davide Noto
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.Mi.S), Policlinico “Paolo Giaccone”, Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Maurizio R. Averna
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.Mi.S), Policlinico “Paolo Giaccone”, Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
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10
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Galiano M, Hammersen J, Sauerstein K, Blessing H, Rümmele P, Purbojo A, Schöber M, Moosmann J, Raffelsbauer G, Heibges A, Klingel R. Homozygous familial hypercholesterolemia with severe involvement of the aortic valve-A sibling-controlled case study on the efficacy of lipoprotein apheresis. J Clin Apher 2020; 35:163-171. [PMID: 32163632 DOI: 10.1002/jca.21772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Homozygous familial hypercholesterolemia (hoFH) can cause severe atherosclerotic cardiovascular disease (ASCVD) in early infancy. Diagnosis and initiation of effective lipid-lowering therapy (LLT) are recommended as early as possible to prevent ASCVD-related morbidity and mortality. METHODS The clinical courses of a pair of siblings with an identical hoFH genotype, who exhibited major similarities of their clinical phenotype were analyzed in a case-control fashion including the family. RESULTS The older sibling was diagnosed with hoFH at the age of 4. Untreated LDL-cholesterol (LDL-C) was 17 mmol/L (660 mg/dL). LLT including lipoprotein apheresis (LA) was initiated and has been successful for 8 years now. A reduction of estimated cholesterol burden by 74% was achieved by LA and combined drug therapy including statins and ezetimibe. The efficacy of escalation of drug therapy was limited because the underlying LDL receptor (LDLR) mutation in the family resulted in substantially reduced receptor function. Treatment with proprotein convertase subtilisin-kexin type 9 (PCSK9)-antibodies failed. His younger brother died at the age of 2 years shortly after the hoFH diagnosis of the elder sibling. Postmortem examination revealed advanced aortic root atheroma and aortic valve stenosis. In the older sibling, aortic valve stenosis and insufficiency were treated at the age of 9 years with mechanical aortic valve replacement. CONCLUSIONS LLT including LA should be initiated as early as possible following the diagnosis of hoFH with very high LDL-C levels. With the same genotype, the phenotype of hoFH can exhibit similar patterns but outcome is substantially related to treatment.
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Affiliation(s)
- Matthias Galiano
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Erlangen University Hospital, Erlangen, Germany
| | - Johanna Hammersen
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Erlangen University Hospital, Erlangen, Germany
| | - Katja Sauerstein
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Erlangen University Hospital, Erlangen, Germany
| | - Holger Blessing
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Erlangen University Hospital, Erlangen, Germany
| | - Petra Rümmele
- Institute for Pathology, Erlangen University Hospital, Erlangen, Germany
| | - Ariawan Purbojo
- Clinic for Pediatric Cardiac Surgery, Erlangen University Hospital, Erlangen, Germany
| | - Martin Schöber
- Clinic for Pediatric Cardiology, Erlangen University Hospital, Erlangen, Germany
| | - Julia Moosmann
- Clinic for Pediatric Cardiology, Erlangen University Hospital, Erlangen, Germany
| | - Gunter Raffelsbauer
- Institute for Forensic Medicine, Erlangen University Hospital, Erlangen, Germany
| | | | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany.,First Department of Internal Medicine, University of Mainz, Mainz, Germany
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Bjelakovic B, Stefanutti C, Pisciotta L, Watts G, Bejiqi R. Homozygous familial hypercholesterolaemia in childhood - The first case report in Southeast Europe. ATHEROSCLEROSIS SUPP 2019; 40:122-124. [PMID: 31818443 DOI: 10.1016/j.atherosclerosissup.2019.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Homozygous familial hypercholesterolaemia (HoFH) is the rare, severe, but treatable disease characterised by exceedingly high levels of low-density lipoprotein cholesterol (LDL-C) and subsequent premature coronary heart disease. Of note, HoFH detection rate and patient access to healthcare and treatment modalities still differ considerably across EU countries. To our current knowledge, there are still no published reports describing HoFH in the paediatric population of Southeastern Europe. In this case report, a few important topics on obstacles in getting adequate health care service and management of HoFH children from Southeastern Europe are tackled.
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Affiliation(s)
- Bojko Bjelakovic
- Clinic of Pediatrics, Clinical Center, Nis, Serbia; University of Nis, Serbia.
| | - Claudia Stefanutti
- Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Immunohematology and Transfusion Medicine, Department of Molecular Medicine, ''Sapienza'' University of Rome, ''Umberto I'' Hospital, Rome, Italy
| | - Livia Pisciotta
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Gerald Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia
| | - Ramush Bejiqi
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 782] [Impact Index Per Article: 156.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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 (TA) 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 Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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13
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Stefanutti C, Pang J, Di Giacomo S, Wu X, Wang X, Morozzi C, Watts GF, Lin J. A cross-national investigation of cardiovascular survival in homozygous familial hypercholesterolemia: The Sino-Roman Study. J Clin Lipidol 2019; 13:608-617. [DOI: 10.1016/j.jacl.2019.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 12/11/2022]
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14
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Efficacy and safety of lipoprotein apheresis in children with homozygous familial hypercholesterolemia: A systematic review. J Clin Lipidol 2019; 13:31-39. [DOI: 10.1016/j.jacl.2018.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 12/16/2022]
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15
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Thompson GR. Atherosclerosis in cholesterol-fed rabbits and in homozygous and heterozygous LDL receptor-deficient humans. Atherosclerosis 2018; 276:148-154. [DOI: 10.1016/j.atherosclerosis.2018.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/10/2018] [Accepted: 07/25/2018] [Indexed: 12/20/2022]
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16
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Mytilinaiou M, Kyrou I, Khan M, Grammatopoulos DK, Randeva HS. Familial Hypercholesterolemia: New Horizons for Diagnosis and Effective Management. Front Pharmacol 2018; 9:707. [PMID: 30050433 PMCID: PMC6052892 DOI: 10.3389/fphar.2018.00707] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/12/2018] [Indexed: 12/11/2022] Open
Abstract
Familial hypercholesterolemia (FH) is a common genetic cause of premature cardiovascular disease (CVD). The reported prevalence rates for both heterozygous FH (HeFH) and homozygous FH (HoFH) vary significantly, and this can be attributed, at least in part, to the variable diagnostic criteria used across different populations. Due to lack of consistent data, new global registries and unified guidelines are being formed, which are expected to advance current knowledge and improve the care of FH patients. This review presents a comprehensive overview of the pathophysiology, epidemiology, manifestations, and pharmacological treatment of FH, whilst summarizing the up-to-date relevant recommendations and guidelines. Ongoing research in FH seems promising and novel therapies are expected to be introduced in clinical practice in order to compliment or even substitute current treatment options, aiming for better lipid-lowering effects, fewer side effects, and improved clinical outcomes.
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Affiliation(s)
- Maria Mytilinaiou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Ioannis Kyrou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom
| | - Mike Khan
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Dimitris K Grammatopoulos
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Harpal S Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.,Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom.,Institute of Precision Diagnostics and Translational Medicine, Coventry and Warwickshire Pathology Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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17
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Klaus G, Taylan C, Büscher R, Schmitt CP, Pape L, Oh J, Driemeyer J, Galiano M, König J, Schürfeld C, Spitthöver R, Schaefer JR, Weber LT, Heibges A, Klingel R. Multimodal lipid-lowering treatment in pediatric patients with homozygous familial hypercholesterolemia-target attainment requires further increase of intensity. Pediatr Nephrol 2018; 33:1199-1208. [PMID: 29502162 DOI: 10.1007/s00467-018-3906-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) causes premature cardiovascular disease (CVD). Lipoprotein apheresis (LA) is recommended as first-line lipid-lowering treatment (LLT) for homozygous (ho) FH. METHODS Efficacy of multimodal LLT including lifestyle counseling, drug treatment, and LA was analyzed in 17 pediatric hoFH or compound heterozygous (c-het) FH patients, who commenced chronic LA in Germany before the age of 18. RESULTS At time of diagnosis, mean low-density lipoprotein cholesterol (LDL-C) concentration was 19.6 mmol/l (756 mg/dl). Multimodal LLT resulted in 73% reduction of mean LDL-C concentration including a 62% contribution of LA. Only three children (18%) achieved mean LDL-C concentrations below the recommended pediatric target of 3.5 mmol/l (135 mg/dl). In 13 patients (76%) during chronic LA, neither cardiovascular events occurred nor was CVD progression detected clinically or by routine imaging techniques. In four patients (24%), cardiovascular events documented progression of CVD despite weekly LA, including one death due to coronary and cerebrovascular CVD which was not stabilized after commencing LA. Based on the mutational status, only 6 out of the 17 children were candidates for proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibition. Two already responded with further LDL-C decrease by 40%. CONCLUSIONS Next to drug therapy, regular LA is an essential component of LLT for approaching LDL-C targets in children with hoFH or c-hetFH, which was successful only in a minority of children. Progression of CVD morbidity and resulting mortality remain unresolved issues. Early and intensified multimodal LLT guided by risk factors beyond LDL-C concentration is needed to improve outcome.
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Affiliation(s)
- Günter Klaus
- Renal Unit, KfH Pediatric Kidney Centre, and Centre for Undiagnosed and Rare Diseases, Marburg, Germany
| | - Christina Taylan
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Rainer Büscher
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Essen University Hospital, Essen, Germany
| | - Claus Peter Schmitt
- Pediatric Nephrology, University Hospital for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Lars Pape
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine and Dermatology, Hannover Medical School, Hannover, Germany
| | - Jun Oh
- Center for Obstetrics and Pediatrics, Department of Pediatrics, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Joenna Driemeyer
- Center for Obstetrics and Pediatrics, Department of Pediatrics, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Matthias Galiano
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Erlangen University Hospital, Erlangen, Germany
| | - Jens König
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Münster University Hospital, Münster, Germany
| | | | | | - Juergen R Schaefer
- Renal Unit, KfH Pediatric Kidney Centre, and Centre for Undiagnosed and Rare Diseases, Marburg, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Andreas Heibges
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany
| | - Reinhard Klingel
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany.
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18
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Klinkmann H, Behm E, Ivanovich P. Removal of Low Density Lipoproteins (LDL) from Plasma: The State of the Art. Int J Artif Organs 2018. [DOI: 10.1177/039139888901200401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- H. Klinkmann
- Clinic for Internal Medicine of the University Wilhelm-Pieck, Rostock -DDR/GDR
| | - E. Behm
- Clinic for Internal Medicine of the University Wilhelm-Pieck, Rostock -DDR/GDR
| | - P. Ivanovich
- V.A. Lakeside Medical Center, Northwestern University, Medical School, Chicago - USA
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19
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Busnach G, Dal Col A, Perrino M, Brando B, Brunati C, Minetti L. Performance Evaluation of Cascade Filtration with High Flow Rate Recirculating Plasma on the Secondary Filter. Int J Artif Organs 2018. [DOI: 10.1177/039139888701000212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cascade filtration (CF) has been performed in 67 on-line procedures in 9 normolipidemic patients with paraproteinemic disorders. A modified dead-end technique has been employed, with high flow rate recirculating plasma on the plasma fractionation filter (QD recycled CF), and an albumin-rich, globulin-poor filtrate was reinfused into the patient. Postprocedure recoveries were 81 ± 15% for albumin, 55 ± 23% for IgM and 48% for cryocrit, with an increase in A/G ratio from 1.8 to 2.1. An improvement was observed also in antiatherogenic/atherogenic lipoproteins ratio, suggesting a possible use of this technique in the treatment of familial hypercholesterolemia. Plasma primary separation was obtained by centrifugation or by filtration, and no significant differences were observed on subsequent protein fractionation process. An albumin priming of the plasmafractionation circuit accounted for an additional 13% saving in postprocedure level. Different surface area secondary filters have been employed: with larger surfaces, larger volumes were processed without any increase in the waste volume and with reduced need for washouts, but with an additional loss of small molecules possibly due to entrapping onto the membrane.
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Affiliation(s)
- G. Busnach
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
| | - A. Dal Col
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
| | - M.L. Perrino
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
| | - B. Brando
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
| | - C. Brunati
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
| | - L. Minetti
- Divisione di Nefrologia e Dialisi Ospedale Niguarda Ca’ Granda Milano, Italy
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20
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Affiliation(s)
- T Phillips
- Department of Dermatology, London Hospital
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21
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High serum triglyceride concentrations in patients with homozygous familial hypercholesterolemia attenuate the efficacy of lipoprotein apheresis by dextran sulfate adsorption. Atherosclerosis 2018; 270:26-32. [PMID: 29407885 DOI: 10.1016/j.atherosclerosis.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/11/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Maximizing the acute reduction of LDL-cholesterol (C) and lipoprotein (a) (Lp(a)) concentrations in patients with homozygous familial hypercholesterolemia (HoFH) is the main goal of lipoprotein apheresis (LA). The objective of this study was to examine how the pre-LA serum TG concentrations influence the efficacy of LA to acutely reduce LDL-C and Lp(a) concentrations in HoFH patients. METHODS Data from 1761 LA treatments of HoFH patients (n = 10) and compound heterozygous patients (n = 5) collected between 2008 and 2016 were analyzed. These data included the pre- and post-LA concentrations of LDL-C, TGs and Lp(a); volume of filtered plasma; type of LA system used (dextran sulfate adsorption (DSA) or heparin-induced extracorporeal LDL precipitation (HELP)); and interval between treatments. RESULTS A significant association between the pre-LA TG concentrations and acute LA-induced reduction in LDL-C, modified by the type of LA system used, was observed (ppre-LA TG quartile*LA system = .04). Using the DSA system, the acute reduction of the LDL-C concentrations was attenuated by 3.9% when the pre-LA TG concentrations were >2.09 mmol/L vs. ≤0.93 mmol/L (highest vs. lowest quartiles: -59.4% vs. -63.3%, p = .007). Using the HELP system, no significant difference was observed in the reduction of LDL-C between the highest and the lowest quartiles of serum TGs (-65.8% vs. -66.4%, p = .9). No association was observed between pre-LA TG concentrations and acute LA-induced decrease in Lp(a) (p = .2). CONCLUSIONS The efficacy of LA is inversely associated with pre-LA TG concentrations in HoFH patients who used the DSA system instead of the HELP system.
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22
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Giannini G, Valbonesi M, Morelli F, Carlier P, De Luigi MC, Dejana AM, Ruzzenenti MR. Hypertriglyceridemia: Apheretic Treatment. Int J Artif Organs 2018; 28:1018-24. [PMID: 16288440 DOI: 10.1177/039139880502801009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with extremely high triglyceride levels and associated lipemia are at high risk for acute pancreatitis. Two factors can increase triglyceride-rich lipoproteins; one is overproduction and other is a defect in clearance. Either mechanism can cause hypertriglyceridemia and both may exist simultaneously. Causes can be either primary or secondary. Plasmapheresis is efficacious for severe hypertryceridemia in patients who have not responded to previous therapies. We have treated 15 cases of hypertrygliceridemia complicating the course of patients receiving Cyclosporin A after bone marrow transplantation. Five patients were treated with plasmapheresis, the other ten with cascade filtration. The removal rate for triglycerides was 58.0% for patients treated by cascade filtration and 63.5% for patients treated by plasmapheresis. The removal rates for triglycerides were low possibly as a consequence of early saturation of the filter.
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Affiliation(s)
- G Giannini
- Department of Immunohematology, Immunohematology Services, S. Martino University Hospital, Genova--Italy.
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23
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Greene O, Durrington P. Clinical Management of Children and Young Adults with Heterozygous Familial Hypercholesterolaemia in the UK. J R Soc Med 2017; 97:226-9. [PMID: 15121812 PMCID: PMC1079462 DOI: 10.1177/014107680409700505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Life expectancy in familial hypercholesterolaemia (FH) has been greatly improved by the advent of statin therapy. In the UK, however, these agents are not licensed for use in children. We approached 169 physicians responsible for lipid clinics for information on their practice in young patients, and valid responses were received from 54%. A typical lipid clinic has only 3.5 patients aged under 16 with FH. In boys aged 10-15 years 65% of physicians were prepared to treat with bile acid sequestrants but only 23% with statins. There was greater reluctance to treat in girls of the same age, corresponding figures being 52% and 12%. Despite the efficacy of statins in reducing low-density-lipoprotein cholesterol, these agents are little used in children with FH. Their safety and clinical efficacy should be assessed by a randomized double-blind trial.
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Affiliation(s)
- Owen Greene
- University Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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24
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Stefanutti C, Mazza F, Pasqualetti D, Di Giacomo S, Watts GF, Massari MS, de Neve J, Morozzi C, Fischer M. Lipoprotein apheresis downregulates IL-1α, IL-6 and TNF-α mRNA expression in severe dyslipidaemia. ATHEROSCLEROSIS SUPP 2017; 30:200-208. [DOI: 10.1016/j.atherosclerosissup.2017.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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25
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Drouin-Chartier JP, Tremblay AJ, Bergeron J, Laflamme N, Lamarche B, Couture P. Impact of lipoprotein apheresis with dextran-sulfate adsorption on the expression of genes involved in cardiovascular health in the blood of patients with homozygous familial hypercholesterolemia. J Clin Apher 2017; 33:104-107. [PMID: 28712132 DOI: 10.1002/jca.21569] [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: 04/10/2017] [Revised: 06/01/2017] [Accepted: 07/05/2017] [Indexed: 12/21/2022]
Abstract
Lipoprotein apheresis (LA) with dextran sulfate adsorption (DSA) is a reliable method to decrease LDL-cholesterol (C) concentrations in patients with homozygous familial hypercholesterolemia (HoFH). The objective of the present study was to investigate the impact of LA with DSA on the mRNA expression of genes associated with cardiovascular health in the whole blood of HoFH patients. Blood samples were collected before and after LA treatment with DSA in 9 HoFH patients. Microarray analyses were performed to measure the whole blood expression of >30 000 annotated genes pre- and post-LA. Concomitant reductions in LDL-C (median -73.8%, range: -55.9 to -82.0, P = .0001) and lipoprotein (a) concentrations (median -74.1%, range -65.6 to -84.1, P = .003) were induced with LA treatment. LA with DSA did not impact the whole blood mRNA expression of most key genes involved in cardiovascular health, including those associated with cholesterol, fatty acid and lipoprotein metabolism. However, LA with DSA significantly upregulated the whole blood expression of early growth response protein (EGR)1 (1.94-fold, P = .02), EGR3 (1.56-fold, P = .0008) and B-cell lymphoma 3-encoded protein (BCL3; 1.25-fold, P = .03). In conclusion, this study demonstrated that a single LA treatment with DSA has very limited impact on the whole blood expression of a broad spectrum of genes associated with cardiovascular health. Our results suggest that contact between blood cells and the primary membrane or extracorporeal circulation could upregulate the expression of EGR1, EGR3, BCL3, and MMP9 in blood cells.
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Affiliation(s)
- Jean-Philippe Drouin-Chartier
- Institute on Nutrition and Functional Foods, Department of Medicine, Laval University, Québec, Canada.,Lipid Clinic and Lipid Research Center, Department of Medicine, CHU de Québec-Université Laval, Québec, Canada
| | - André J Tremblay
- Institute on Nutrition and Functional Foods, Department of Medicine, Laval University, Québec, Canada
| | - Jean Bergeron
- Lipid Clinic and Lipid Research Center, Department of Medicine, CHU de Québec-Université Laval, Québec, Canada
| | - Nathalie Laflamme
- Lipid Clinic and Lipid Research Center, Department of Medicine, CHU de Québec-Université Laval, Québec, Canada
| | - Benoît Lamarche
- Institute on Nutrition and Functional Foods, School of Nutrition, Laval University, Québec, Canada
| | - Patrick Couture
- Institute on Nutrition and Functional Foods, Department of Medicine, Laval University, Québec, Canada.,Lipid Clinic and Lipid Research Center, Department of Medicine, CHU de Québec-Université Laval, Québec, Canada
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26
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Toward an international consensus—Integrating lipoprotein apheresis and new lipid-lowering drugs. J Clin Lipidol 2017; 11:858-871.e3. [DOI: 10.1016/j.jacl.2017.04.114] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/30/2017] [Accepted: 04/15/2017] [Indexed: 12/11/2022]
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27
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Thompson GR, Blom DJ, Marais AD, Seed M, Pilcher GJ, Raal FJ. Survival in homozygous familial hypercholesterolaemia is determined by the on-treatment level of serum cholesterol. Eur Heart J 2017; 39:1162-1168. [DOI: 10.1093/eurheartj/ehx317] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/25/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Gilbert R Thompson
- Department of Metabolic Medicine, Faculty of Medicine, Imperial College London, Hammersmith Campus, Ducane Road, London W12 0NN, UK
| | - Dirk J Blom
- Division of Lipidology, Department of Medicine, UCT Faculty Health Sciences, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - A David Marais
- Division of Chemical Pathology, Department of Pathology, UCT Faculty Health Sciences, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - Mary Seed
- Department of Cardiology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Gillian J Pilcher
- Carbohydrate and Lipid Metabolism Research Unit, Department of Medicine, University of the Witwatersrand, 7 York Rd, Parktown 2193, Johannesburg, South Africa
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Department of Medicine, University of the Witwatersrand, 7 York Rd, Parktown 2193, Johannesburg, South Africa
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28
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Widhalm K, Benke IM, Fritz M, Geiger H, Helk O, Fritsch M, Hoermann G, Kostner G. Homozygous familial hypercholesterolemia: Summarized case reports. Atherosclerosis 2017; 257:86-89. [PMID: 28126585 DOI: 10.1016/j.atherosclerosis.2017.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/28/2016] [Accepted: 01/11/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND AIMS Homozygous familial hypercholesterolemia (hoFH) is a rare genetic disorder with potential severe atherosclerosis in the pediatric age. METHODS We report on 9 patients with hoFH, who had been diagnosed within the last 30 years and who were consequently treated with apheresis and drugs. RESULTS Two deaths occurred: one at age 36 years and the other at age four and a half years before effective treatment was commenced. All other patients are still in good clinical condition today, although four of them have proven aortic stenosis or arterial plaques. CONCLUSIONS Our case report highlights that adequate treatment should start as early as possible to delay the onset of clinical manifestations of atherosclerosis. It can be assumed that the introduction of new drugs can improve the outcome and possibly lengthen the life expectancy of patients affected by hoFH.
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Affiliation(s)
- Kurt Widhalm
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria.
| | - Ina Michel Benke
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Michael Fritz
- Hospital Feldkirch, Department of Pediatrics, Austria
| | | | - Oliver Helk
- Institute for Medical Sciences, University of Aberdeen, UK
| | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Austria
| | - Gerhard Kostner
- Department of Biochemistry, Medical University of Graz, Austria
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29
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Vogt A. The Italian Consensus Conferences on low density lipoprotein-cholesterol apheresis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:1-3. [PMID: 27416572 PMCID: PMC5269421 DOI: 10.2450/2016.0058-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Anja Vogt
- Medizinische Klinik und Poliklinik IV, Klinikum der Unversitat Munchen, Germany
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30
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France M, Rees A, Datta D, Thompson G, Capps N, Ferns G, Ramaswami U, Seed M, Neely D, Cramb R, Shoulders C, Barbir M, Pottle A, Eatough R, Martin S, Bayly G, Simpson B, Halcox J, Edwards R, Main L, Payne J, Soran H. HEART UK statement on the management of homozygous familial hypercholesterolaemia in the United Kingdom. Atherosclerosis 2016; 255:128-139. [DOI: 10.1016/j.atherosclerosis.2016.10.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/03/2016] [Accepted: 10/07/2016] [Indexed: 12/16/2022]
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Abstract
Homozygous familial hypercholesterolaemia (HoFH) is an inherited disease causing an approximately fourfold increase in blood low-density lipoprotein cholesterol (LDLC) from birth compared with the age-matched normal population owing to reduced low-density lipoprotein receptor (LDLR) activity. Such elevated cholesterol is associated with accelerated atheromatous disease, particularly of the aortic root and coronary arteries. However, HoFH is clinically heterogeneous, reflecting residual low-density lipoprotein receptor (LDLR) activity. The main objective in treating children may be stated to be the avoidance of irreversible cardiac damage requiring heart transplantation by sufficient lowering of blood cholesterol. Lipoprotein apheresis or plasmapheresis are safe means of lowering cholesterol but may be insufficient on their own. Statin drugs, PCSK9 inhibitors ezetimibe and bile acid sequestrants are relatively ineffective if LDLR activity is lacking, but should be used if effective. Two new drugs, lomitapide and mipomersen, have been licensed specifically for HoFH by some regulatory authorities. They work by reducing LDL production rate. They have been associated with fatty liver in adults. Evidence of safety in children is lacking. An alternative is liver transplantation, which replaces the missing LDLR and normalises cholesterol. Clinicians are faced with a dilemma in choosing between these options or deferring such treatment associated with potential harm. Individual case descriptions are an important means of informing clinical judgement. Management of the two cases described in this issue is discussed in the light of modern developments in transplantation and pharmacotherapy.
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Key Words
- ADH, autosomal dominant hypercholesterolaemia, refers to hypercholesterolaemia owing to a single mutation of an allele of a gene affecting LDLR activity
- APOB, apolipoprotein B, is the main protein component of LDL and is the ligand for LDL receptors in the liver
- ARH, autosomal recessive hypercholesterolaemia, refers to hypercholesterolaemia owing to a mutation of both alleles of a single gene affecting LDLR activity
- Evolucomab
- FH, familial hypercholesterolaemia, is an inherited condition causing reduced LDLR activity with consequent hypercholesterolaemia
- HeFH, heterozygous familial hypercholesterolaemia, is caused by one mutant allele of genes affecting LDLR activity
- HoFH, homozygous familial hypercholesterolaemia is caused by two mutant alleles of genes affecting LDLR activity
- Homozygous familial hypercholesterolaemia
- LDL, low-density lipoprotein, is a complex of cholesterol attached to a lipoprotein particle which is removed from blood mainly by the liver
- LDLC, LDL cholesterol, refers to the cholesterol component of LDL
- LDLR, LDL receptors, mediate LDL uptake by the liver
- LDLRAP1, a protein called LDLR adaptor protein 1, facilitates LDLR function
- Lipoprotein apheresis
- Liver transplantation
- Lomitapide
- Microsomal triglyceride transfer protein is an enzyme involved in the hepatic assembly of triglyceride, cholesterol and APOB into triglyceride-rich particles which are secreted by the liver. These particles are metabolised to LDL
- PCSK9
- PCSK9, a protein called proprotein convertase subtilisin/kexin type 9, increases the rate of degradation of LDLR
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Affiliation(s)
- Michael France
- a Cardiovascular Trials Unit , Central Manchester University Hospitals Foundation Trust and Cardiovascular Research Group, University of Manchester , Manchester , UK
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32
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Khoo KL, Page MM, Liew YM, Defesche JC, Watts GF. Ten years of lipoprotein apheresis for familial hypercholesterolemia in Malaysia: A creative approach by a cardiologist in a developing country. J Clin Lipidol 2016; 10:1188-94. [DOI: 10.1016/j.jacl.2016.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/13/2016] [Accepted: 05/06/2016] [Indexed: 12/01/2022]
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33
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Al-Ashwal A, Alnouri F, Sabbour H, Al-Mahfouz A, Al-Sayed N, Razzaghy-Azar M, Al-Allaf F, Al-Waili K, Banerjee Y, Genest J, Santos RD, Al-Rasadi K. Identification and Treatment of Patients with Homozygous Familial Hypercholesterolaemia: Information and Recommendations from a Middle East Advisory Panel. Curr Vasc Pharmacol 2016; 13:759-70. [PMID: 26311574 PMCID: PMC4997916 DOI: 10.2174/1570161113666150827125040] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/15/2015] [Accepted: 07/09/2015] [Indexed: 01/06/2023]
Abstract
We present clinical practice guidelines for the diagnosis and treatment of homozygous familial hypercholesterolaemia (HoFH) in the Middle East region. While guidelines are broadly applicable in Europe, in the Middle East we experience a range of confounding factors that complicate disease management to a point whereby the European guidance cannot be applied without significant modification. Specifically, for disease prevalence, the Middle East region has an established epidemic of diabetes and metabolic syndrome that can complicate treatment and mask a clinical diagnosis of HoFH. We have also a high incidence of consanguineous marriages, which increase the risk of transmission of recessive and homozygous genetic disorders. This risk is further augmented in autosomal dominant disorders such as familial
hypercholesterolaemia (FH), in which a range of defective genes can be transmitted, all of which contribute to the phenotypic expression of the disease. In terms of treatment, we do not have access to lipoprotein apheresis on the same scale as in Europe, and there remains a significant reliance on statins, ezetimibe and the older plasma exchange methods. Additionally, we do not have widespread access to anti-apolipoprotein B therapies and microsomal transfer protein inhibitors. In order to adapt existing global guidance documents on HoFH to the Middle East region, we convened a panel of experts from Oman, Saudi Arabia, UAE, Iran and Bahrain to draft a regional guidance document for HoFH. We also included selected experts from outside the region. This panel statement will form the foundation of a detailed appraisal of the current FH management in the Middle Eastern population and thereby provide a suitable set of guidelines tailored for the region.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Khalid Al-Rasadi
- Department of Clinical Biochemistry, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman.
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Al-Dughaishi T, Al-Waili K, Banerjee Y, Sheik S, Al-Sabti H, Al-Zakwani I, Al-Mukhaini S, Al Wahaibi K, Al-Hinai AT, Al-Rasadi K. Successful Direct Adsorption of Lipoproteins (DALI) Apheresis During Pregnancy in an Omani Woman with Homozygous Familial Hypercholesterolemia. Open Cardiovasc Med J 2015; 9:114-7. [PMID: 27006714 PMCID: PMC4768655 DOI: 10.2174/1874192401509010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/20/2015] [Accepted: 10/22/2015] [Indexed: 01/19/2023] Open
Abstract
We report our experience with Direct Adsorption of Lipoproteins (DALI) apheresis in an Omani pregnant woman affected by homozygous familial hypercholesterolemia. To the best of our knowledge this is the first successful pregnancy treated with DALI apheresis. The patient had a history of coronary artery disease, supra-aortic valvular stenosis and severe carotid artery disease with right carotid artery stenting. She was on a regular biweekly DALI apheresis since 2008. In May 2013, she became pregnant and rosuvastatin and ezetimibe were stopped while she continued on DALI apheresis biweekly. This treatment during pregnancy was successful with no major complications. The average low-density lipoprotein cholesterol reduction during therapy was 50%. She spontaneously delivered a healthy male infant (2,400 g) at 37 weeks. We showed that DALI apheresis therapy was safe during pregnancy with a good outcome for both mother and neonate.
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Affiliation(s)
- Tamima Al-Dughaishi
- Department of Obstetrics & Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalid Al-Waili
- Department of Clinical Biochemistry, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yajnavalka Banerjee
- Department of Biochemistry, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Shahila Sheik
- Department of Obstetrics & Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Hilal Al-Sabti
- Department of Surgery, Cardiothoracic Unit, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos
University, Muscat, Oman
- Gulf Health Research, Muscat, Oman
| | - Suad Al-Mukhaini
- Department of Nursing, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalifa Al Wahaibi
- Department of Surgery, Vascular Unit, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Khalid Al-Rasadi
- Department of Clinical Biochemistry, Sultan Qaboos University Hospital, Muscat, Oman
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Thompson GR, Seed M, Naoumova RP, Neuwirth C, Walji S, Aitman TJ, Scott J, Myant NB, Soutar AK. Improved cardiovascular outcomes following temporal advances in lipid-lowering therapy in a genetically-characterised cohort of familial hypercholesterolaemia homozygotes. Atherosclerosis 2015; 243:328-33. [DOI: 10.1016/j.atherosclerosis.2015.09.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/12/2015] [Accepted: 09/21/2015] [Indexed: 12/31/2022]
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36
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Saheb S. La LDL-aphérèse : principes et indications. Transfus Clin Biol 2015. [DOI: 10.1016/j.tracli.2015.06.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ahmad Z, Khera A. The role of microsomal triglyceride transfer protein inhibitors in the treatment of patients with familial hypercholesterolemia: risks, benefits, and management. Curr Atheroscler Rep 2015; 17:469. [PMID: 25408543 DOI: 10.1007/s11883-014-0469-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Statins fail to adequately reduce low-density lipoprotein-cholesterol (LDL-C) in patients with homozygous familial hypercholesterolemia, requiring these patients to undergo weekly or bi-weekly sessions of LDL apheresis. Although efficacious, LDL apheresis is an invasive procedure with high cost and low availability, and additional options, such as inhibitors of microsomal transfer protein (MTP), may have benefit. Inhibition of MTP reduces levels of circulating cholesterol and triglycerides by preventing the formation of very-low-density lipoprotein and chylomicrons. LDL-C levels decrease by as much as 50%. Unfortunately, adverse effects-the most common of which are gastrointestinal-related and hepatic lipid accumulation-limit broader use of the drug. Furthermore, the cardiovascular benefit of MTP inhibition remains unclear. However, MTP inhibition offers a viable additional lipid-lowering option for patients with homozygous familial hypercholesterolemia.
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Affiliation(s)
- Zahid Ahmad
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA,
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38
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Sjouke B, Hovingh GK, Kastelein JJP, Stefanutti C. Homozygous autosomal dominant hypercholesterolaemia: prevalence, diagnosis, and current and future treatment perspectives. Curr Opin Lipidol 2015; 26:200-9. [PMID: 25950706 DOI: 10.1097/mol.0000000000000179] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Barbara Sjouke
- aDepartment of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands bDepartment of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit - Lipid Clinic and Atherosclerosis Prevention Centre, 'Sapienza' University of Rome, Rome, Italy
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Najam O, Ray KK. Familial Hypercholesterolemia: a Review of the Natural History, Diagnosis, and Management. Cardiol Ther 2015; 4:25-38. [PMID: 25769531 PMCID: PMC4472649 DOI: 10.1007/s40119-015-0037-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Indexed: 12/17/2022] Open
Abstract
Familial hypercholesterolemia (FH) is an inherited disorder of lipid metabolism characterized by premature cardiovascular disease. It is one of the most common metabolic disorders affecting humans. There are two clinical manifestations: the milder heterozygous form and more severe homozygous form. Despite posing a significant health risk, FH is inadequately diagnosed and managed. As the clinical outcome is related to the degree and duration of exposure to elevated low-density lipoprotein cholesterol (LDL-C) levels, early treatment is vital. Diagnosis can usually be made using a combination of clinical characteristics such as family history, lipid levels, and genetic testing. Mutations in the gene encoding the LDL receptor (LDLR), apolipoprotein B, the pro-protein convertase subtilisin/kexin 9 (PCSK9), and LDLR adaptor protein are the commonest abnormalities. Early identification and treatment of patients, as well as screening of relatives, helps significantly reduce the risk of premature disease. Although statins remain the first-line therapy in most cases, monotherapy is usually inadequate to control elevated LDL-C levels. Additional therapy with ezetimibe and bile acid sequestrants may be required. Newer classes of pharmacotherapy currently under investigation include lomitapide, mipomersen, and monoclonal antibodies to PCSK9. Lipoprotein apheresis may be required when multiple pharmacotherapies are inadequate, especially in the homozygous form. Effective early detection and treatment of the index individual and initiation of cascade screening will help reduce the complications associated with FH. In this article, we review the disease of FH, complexity of diagnosis and management, and the challenges faced in preventing the significant morbidity and mortality associated with it.
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Affiliation(s)
- Osman Najam
- Cardiovascular Sciences Research Centre, St George's University, London, UK
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Stefanutti C, Thompson GR. Lipoprotein Apheresis in the Management of Familial Hypercholesterolaemia: Historical Perspective and Recent Advances. Curr Atheroscler Rep 2014; 17:465. [DOI: 10.1007/s11883-014-0465-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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42
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Connolly KD, Willis GR, Datta DBN, Ellins EA, Ladell K, Price DA, Guschina IA, Rees DA, James PE. Lipoprotein-apheresis reduces circulating microparticles in individuals with familial hypercholesterolemia. J Lipid Res 2014; 55:2064-72. [PMID: 25121984 PMCID: PMC4173999 DOI: 10.1194/jlr.m049726] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein-apheresis (apheresis) removes LDL-cholesterol in patients with severe dyslipidemia. However, reduction is transient, indicating that the long-term cardiovascular benefits of apheresis may not solely be due to LDL removal. Microparticles (MPs) are submicron vesicles released from the plasma membrane of cells. MPs, particularly platelet-derived MPs, are increasingly being linked to the pathogenesis of many diseases. We aimed to characterize the effect of apheresis on MP size, concentration, cellular origin, and fatty acid concentration in individuals with familial hypercholesterolemia (FH). Plasma and MP samples were collected from 12 individuals with FH undergoing routine apheresis. Tunable resistive pulse sensing (np200) and nanoparticle tracking analysis measured a fall in MP concentration (33 and 15%, respectively; P < 0.05) pre- to post-apheresis. Flow cytometry showed MPs were predominantly annexin V positive and of platelet (CD41) origin both pre- (88.9%) and post-apheresis (88.4%). Fatty acid composition of MPs differed from that of plasma, though apheresis affected a similar profile of fatty acids in both compartments, as measured by GC-flame ionization detection. MP concentration was also shown to positively correlate with thrombin generation potential. In conclusion, we show apheresis nonselectively removes annexin V-positive platelet-derived MPs in individuals with FH. These MPs are potent inducers of coagulation and are elevated in CVD; this reduction in pathological MPs could relate to the long-term benefits of apheresis.
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Affiliation(s)
- Katherine D Connolly
- Institute of Molecular and Experimental Medicine School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
| | - Gareth R Willis
- Institute of Molecular and Experimental Medicine School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
| | - Dev B N Datta
- Lipid Unit, Llandough Hospital, Cardiff CF64 2XX, United Kingdom
| | - Elizabeth A Ellins
- Institute of Molecular and Experimental Medicine School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom Institute of Life Sciences, College of Medicine, Swansea University, Singleton Park, Swansea SA2 8PP, United Kingdom
| | - Kristin Ladell
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
| | - David A Price
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
| | - Irina A Guschina
- School of Biosciences, Cardiff University, Cardiff CF10 3AX, United Kingdom
| | - D Aled Rees
- Institute of Molecular and Experimental Medicine School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
| | - Philip E James
- Institute of Molecular and Experimental Medicine School of Medicine, Cardiff University, Cardiff CF14 4XN, United Kingdom
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Klose G, Laufs U, März W, Windler E. Familial hypercholesterolemia: developments in diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:523-9. [PMID: 25145510 PMCID: PMC4148715 DOI: 10.3238/arztebl.2014.0523] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 08/25/2013] [Accepted: 03/21/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is a congenital disorder of lipid metabolism characterized by a marked elevation of the plasma concentration of LDL (low-density lipoprotein) cholesterol beginning in childhood and by the early onset of coronary heart disease. It is among the commonest genetic disorders, with an estimated prevalence in Germany of at least 1 per 500 persons. METHOD Review of pertinent literature retrieved by a selective search. RESULTS FH is underdiagnosed and undertreated in Germany. It is clinically diagnosed on the basis of an elevated LDL cholesterol concentration (>190 mg/dL [4.9 mmol/L]), a family history of hypercholesterolemia, and early coronary heart disease, or the demonstration of xanthomas. The gold standard of diagnosis is the identification of the underlying genetic defect, which is possible in 80% of cases and enables the identification of affected relatives of the index patient. The recommended goals of treatment, based on the results of observational studies, are to lower the LDL cholesterol concentration by at least 50% or to less than 100 mg/dL (2.6 mmol/L) (for children: <135 mg/dL [3.5 mmol/L]). The target value is lower for patients with clinically overt atherosclerosis (<70 mg/dL [1.8 mmol/L]). Statins, combined with a health-promoting lifestyle, are the treatment of choice. Lipoprotein apheresis is used in very severe cases; its therapeutic effects on clinical endpoints and its side effect profile have not yet been documented in randomized controlled trials. CONCLUSION Familial hypercholesterolemia is a common disease that can be diagnosed simply and reliably on clinical grounds and by molecular genetic testing. Timely diagnosis and appropriate treatment can lower the risk of atherosclerosis in heterozygous patients to that of the general population.
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Affiliation(s)
- Gerald Klose
- Private practice for Internal Medicine, Gastroenterology, Cardiology and Preventional Medicine: Dres. T. Beckenbauer und S. Maierhof and joint practice Dres. K. W. Spieker and I van de Loo, Bremen
| | - Ulrich Laufs
- Department of Internal Medicine III—Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg/Saar
| | - Winfried März
- Medical Clinic V (Nephrology, Hypertensiology, Endocrinology, Diabetology, Rheumatology), Department of Internal Medicine, Mannheim Medical Faculty, University of Heidelberg, Mannheim
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University Graz
- Synlab Academy, Synlab Services GmbH, Mannheim
| | - Eberhard Windler
- Preventive Medicine, Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg
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Page MM, Bell DA, Hooper AJ, Watts GF, Burnett JR. Lipoprotein apheresis and new therapies for severe familial hypercholesterolemia in adults and children. Best Pract Res Clin Endocrinol Metab 2014; 28:387-403. [PMID: 24840266 DOI: 10.1016/j.beem.2013.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Michael M Page
- Lipid Disorders Clinic, Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Damon A Bell
- Lipid Disorders Clinic, Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Amanda J Hooper
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia; School of Pathology & Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Gerald F Watts
- Lipid Disorders Clinic, Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - John R Burnett
- Lipid Disorders Clinic, Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
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45
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France M, Schofield J, Kwok S, Soran H. Treatment of homozygous familial hypercholesterolemia. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/clp.13.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Panno MD, Cefalù AB, Averna MR. Lomitapide: a novel drug for homozygous familial hypercholesterolemia. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/clp.13.74] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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47
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Walji S, Neuwirth C, Thompson GR. Lipoprotein apheresis for the treatment of familial hypercholesterolemia. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/clp.13.57] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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The evidence-base for the efficacy of lipoprotein apheresis in combating cardiovascular disease. ATHEROSCLEROSIS SUPP 2013; 14:67-70. [PMID: 23357143 DOI: 10.1016/j.atherosclerosissup.2012.10.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Emerging low-density lipoprotein (LDL) therapies: Management of severely elevated LDL cholesterol—The role of LDL-apheresis. J Clin Lipidol 2013; 7:S21-6. [DOI: 10.1016/j.jacl.2013.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/18/2013] [Accepted: 03/18/2013] [Indexed: 11/21/2022]
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50
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Borberg H. The lower the better: target values after LDL-Apheresis and semi-selective LDL-elimination therapies. Transfus Apher Sci 2013; 48:203-6. [PMID: 23597601 DOI: 10.1016/j.transci.2013.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Prior to 1980 the drug therapy of hereditary hypercholesterolaemia was, as compared to nowadays standards, rather limited. There was virtually no effective therapy for homozygous patients, though plasma exchange introduced in France and Britain, demonstrated the use-fullness of the introduction of apheresis techniques. Parallel to the improvement of cholesterol lowering drug therapy for heterozygous patients, apheresis was developed as therapeutic affinity chromatography since 1980 at the university of Cologne for both homozygous and therapy refractory heterozygous patients. This development was named LDL-Apheresis based on the specificity for the removal of Apoprotein B bound cholesterol, the capacity due to the development of a repetitive cycling technique and the economy determined from the reuse of affinity chromatography columns for each single patient. The capacity of the system allowed for the introduction of new standards of post-treatment values such as 100mg/dl total cholesterol or alternatively 50mg/dl LDL-cholesterol and if cholesterol lowering drugs can also applied for a limited extent the rebound can be also slowed down. After 33 years of experience with seven homozygotes and 32 heterozygotes without treatment alternative, we found that in addition to the improvement of the quality of live the extension of live expectancy are the real proof of a therapeutic success as compared to other diagnostic procedures. The average live expectancy of our seven homozygous patients is 45.6 years; our oldest heterozygous patient is 81 years. There are no comparable long term data at present available neither from studies using drugs nor from subsequently developed apheresis techniques which also removed LDL-cholesterol together with plasma constituents not participating in the development of atherosclerosis. Also two homozygous patients giving birth to four children without complication support our concept of aggressive cholesterol lowering therapy being without major side effects (3-4% minor undesired reactions).
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Affiliation(s)
- Helmut Borberg
- German Haemapheresis Centre, Deutsches Haemapherese Zentrum, Maarweg 165, Cologne, Germany.
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