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Jung Y, Nelson HA, Lin DMH. Use of therapeutic plasma exchange to remove lipoprotein X in a patient with vanishing bile duct syndrome presenting with cholestasis, pseudohyponatremia, and hypercholesterolemia: A case report and review of literature. J Clin Apher 2024; 39:e22105. [PMID: 38334173 DOI: 10.1002/jca.22105] [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: 04/22/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Lipoprotein X (Lp-X) is an abnormal lipoprotein found in multiple disease conditions, including liver dysfunction and cholestasis. High Lp-X concentrations can interfere with some laboratory testing that may result in spurious results. The detection of Lp-X can be challenging, and there is currently a lack of consensus regarding the management of Lp-X other than treating the underlying disease. CASE PRESENTATION A 42-year-old female with Hodgkin's lymphoma treated with dexamethasone, high dose cytarabine and cisplatin and vanishing bile duct syndrome confirmed by liver biopsy presented with cholestasis, pseudohyponatremia (sodium, 113 mmol/L; reference range 136-146 mmL/L; serum osmolality, 303 mOsm/kg), and hypercholesterolemia (> 2800 mg/dL, reference range < 200 mg/dL). Lp-X was confirmed by lipoprotein electrophoresis (EP). Although she did not manifest any specific signs or symptoms, therapeutic plasma exchange (TPE) was initiated based on laboratory findings of extreme hypercholesterolemia, spuriously abnormal serum sodium, and HDL values, and the potential for short- and long-term sequelae such as hyperviscosity syndrome, xanthoma, and neuropathy. During the hospitalization, she was treated with four 1.0 plasma volume TPE over 6 days using 5% albumin for replacement fluid. After the first TPE, total cholesterol (TC) decreased to 383 mg/dL and sodium was measured at 131 mmol/L. The patient was transitioned into outpatient maintenance TPE to eliminate the potential of Lp-X reappearance while the underlying disease was treated. Serial follow-up laboratory testing with lipoprotein EP showed the disappearance of Lp-X after nine TPEs over a 10-week period. LITERATURE REVIEW There are seven and four case reports of Lp-X treated with TPE and lipoprotein apheresis (LA), respectively. While all previous case reports showed a reduction in TC levels, none had monitored the disappearance of Lp-X after completing a course of therapeutic apheresis. CONCLUSION Clinicians should have a heightened suspicion for the presence of abnormal Lp-X in patients with cholestasis, hypercholesterolemia, and pseudohyponatremia. Once Lp-X is confirmed by lipoprotein EP, TPE should be initiated to reduce TC level and remove abnormal Lp-X. Most LA techniques are not expected to be beneficial since Lp-X lacks apolipoprotein B. Therefore, we suggest that inpatient course of TPE be performed every other day until serum sodium, TC and HDL levels become normalized. Outpatient maintenance TPE may also be considered to keep Lp-X levels low while the underlying disease is treated. Serum sodium, TC, and HDL levels should be monitored while on maintenance TPE.
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Affiliation(s)
- Yujung Jung
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah Health, Salt Lake City, Utah, USA
- ARUP Institute for Clinical and Experimental Pathology®, Salt Lake City, Utah, USA
| | - David Ming-Hung Lin
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Garcia E, Shalaurova I, Matyus SP, Freeman LA, Neufeld EB, Sampson ML, Zubirán R, Wolska A, Remaley AT, Otvos JD, Connelly MA. A High-Throughput NMR Method for Lipoprotein-X Quantification. Molecules 2024; 29:564. [PMID: 38338310 PMCID: PMC10856374 DOI: 10.3390/molecules29030564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/02/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Lipoprotein X (LP-X) is an abnormal cholesterol-rich lipoprotein particle that accumulates in patients with cholestatic liver disease and familial lecithin-cholesterol acyltransferase deficiency (FLD). Because there are no high-throughput diagnostic tests for its detection, a proton nuclear magnetic resonance (NMR) spectroscopy-based method was developed for use on a clinical NMR analyzer commonly used for the quantification of lipoproteins and other cardiovascular biomarkers. The LP-X assay was linear from 89 to 1615 mg/dL (cholesterol units) and had a functional sensitivity of 44 mg/dL. The intra-assay coefficient of variation (CV) varied between 1.8 and 11.8%, depending on the value of LP-X, whereas the inter-assay CV varied between 1.5 and 15.4%. The assay showed no interference with bilirubin levels up to 317 mg/dL and was also unaffected by hemolysis for hemoglobin values up to 216 mg/dL. Samples were stable when stored for up to 6 days at 4 °C but were not stable when frozen. In a large general population cohort (n = 277,000), LP-X was detected in only 50 subjects. The majority of LP-X positive cases had liver disease (64%), and in seven cases, had genetic FLD (14%). In summary, we describe a new NMR-based assay for LP-X, which can be readily implemented for routine clinical laboratory testing.
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Affiliation(s)
- Erwin Garcia
- Labcorp, Morrisville, NC 27560, USA; (E.G.); (I.S.); (S.P.M.)
| | | | | | - Lita A. Freeman
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
| | - Edward B. Neufeld
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
| | - Maureen L. Sampson
- Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Rafael Zubirán
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
| | - Anna Wolska
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
| | - Alan T. Remaley
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
- Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - James D. Otvos
- Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA; (L.A.F.); (E.B.N.); (R.Z.); (A.W.); (A.T.R.); (J.D.O.)
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Detection of Lipoprotein X (LpX): A challenge in patients with severe hypercholesterolaemia. J Med Biochem 2019; 39:283-289. [PMID: 33269016 DOI: 10.2478/jomb-2019-0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/28/2019] [Indexed: 01/30/2023] Open
Abstract
Background Lipoprotein X (LpX) is an abnormal lipoprotein fraction, which can be detected in patients with severe hypercholesterolaemia and cholestatic liver disease. LpX is composed largely of phospholipid and free cholesterol, with small amounts of triglyceride, cholesteryl ester and protein. There are no widely available methods for direct measurement of LpX in routine laboratory practice. We present the heterogeneity of clinical and laboratory manifestations of the presence of LpX, a phenomenon which hinders LpX detection. Methods The study was conducted on a 26-year-old female after liver transplantation (LTx) with severely elevated total cholesterol (TC) of 38 mmol/L and increased cholestatic liver enzymes. TC, free cholesterol (FC), cholesteryl esters (CE), triglycerides, phospholipids, HDL-C, LDL-C, and apolipoproteins AI and B were measured. TC/apoB and FC:CE ratios were calculated. Lipoprotein electrophoresis was performed using a commercially available kit and laboratory-prepared agarose gel. Results Commercially available electrophoresis failed to demonstrate the presence of LpX. Laboratory-prepared gel clearly revealed the presence of lipoproteins with γ mobility, characteristic of LpX. The TC/apoB ratio was elevated and the CE level was reduced, confirming the presence of LpX. Regular lipoprotein apheresis was applied as the method of choice in LpX disease and a bridge to reLTx due to chronic liver insufficiency. Conclusions The detection of LpX is crucial as it may influence the method of treatment. As routinely available biochemical laboratory tests do not always indicate the presence of LpX, in severe hypercholesterolaemia with cholestasis, any discrepancy between electrophoresis and biochemical tests should raise suspicions of LpX disease.
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Unger LW, Forstner B, Schneglberger S, Muckenhuber M, Eigenbauer E, Scheiner B, Mandorfer M, Trauner M, Reiberger T. Patterns and prevalence of dyslipidemia in patients with different etiologies of chronic liver disease. Wien Klin Wochenschr 2019; 131:395-403. [PMID: 31493100 PMCID: PMC6748890 DOI: 10.1007/s00508-019-01544-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 08/13/2019] [Indexed: 12/14/2022]
Abstract
Background Liver disease impacts on hepatic synthesis of lipoproteins and lipogenesis but data on dyslipidemia during disease progression are limited. We assessed the patterns of dyslipidemia in (i) different liver disease etiologies and discriminated (ii) non-advanced (non-ACLD) from advanced chronic liver disease (ACLD) as it is unclear how progression to ACLD impacts on dyslipidemia-associated cardiovascular risk. Methods Patients with alcoholic liver disease (n = 121), hepatitis C (n = 1438), hepatitis B (n = 384), metabolic/fatty liver disease (n = 532), cholestatic liver disease (n = 119), and autoimmune hepatitis (n = 114) were included. Liver stiffness ≥15 kPa defined ACLD. Dyslipidemia was defined as total cholesterol >200 mg/dL, low-density lipoprotein (LDL)-cholesterol >130 mg/dL and triglycerides >200 mg/dL. Results Across all etiologies, total cholesterol levels were significantly lower in ACLD, when compared to non-ACLD. Accordingly, LDL-cholesterol levels were significantly lower in ACLD due to hepatitis C, hepatitis B, metabolic/fatty liver disease and autoimmune hepatitis. Triglyceride levels did not differ due to disease severity in any etiology. Despite lower total and LDL cholesterol levels in ACLD, etiology-specific dyslipidemia patterns remained similar to non-ACLD. Contrary to this “improved” lipid status in ACLD, cardiovascular comorbidities were more prevalent in ACLD: arterial hypertension was present in 26.6% of non-ACLD and in 55.4% of ACLD patients (p < 0.001), and diabetes was present in 8.1% of non-ACLD and 25.6% of ACLD patients (p < 0.001). Conclusion Liver disease etiology is a major determinant of dyslipidemia patterns and prevalence. Progression to ACLD “improves” serum lipid levels while arterial hypertension and diabetes mellitus are more prevalent. Future studies should evaluate cardiovascular events after ACLD-induced “improvement” of dyslipidemia. Electronic supplementary material The online version of this article (10.1007/s00508-019-01544-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lukas W Unger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Bernadette Forstner
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Stephan Schneglberger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Moritz Muckenhuber
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Ernst Eigenbauer
- IT-Systems & Communications, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria.
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Nemes K, Åberg F, Gylling H, Isoniemi H. Cholesterol metabolism in cholestatic liver disease and liver transplantation: From molecular mechanisms to clinical implications. World J Hepatol 2016; 8:924-932. [PMID: 27574546 PMCID: PMC4976211 DOI: 10.4254/wjh.v8.i22.924] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/07/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
The aim of this review is to enlighten the critical roles that the liver plays in cholesterol metabolism. Liver transplantation can serve as gene therapy or a source of gene transmission in certain conditions that affect cholesterol metabolism, such as low-density-lipoprotein (LDL) receptor gene mutations that are associated with familial hypercholesterolemia. On the other hand, cholestatic liver disease often alters cholesterol metabolism. Cholestasis can lead to formation of lipoprotein X (Lp-X), which is frequently mistaken for LDL on routine clinical tests. In contrast to LDL, Lp-X is non-atherogenic, and failure to differentiate between the two can interfere with cardiovascular risk assessment, potentially leading to prescription of futile lipid-lowering therapy. Statins do not effectively lower Lp-X levels, and cholestasis may lead to accumulation of toxic levels of statins. Moreover, severe cholestasis results in poor micellar formation, which reduces cholesterol absorption, potentially impairing the cholesterol-lowering effect of ezetimibe. Apolipoprotein B-100 measurement can help distinguish between atherogenic and non-atherogenic hypercholesterolemia. Furthermore, routine serum cholesterol measurements alone cannot reflect cholesterol absorption and synthesis. Measurements of serum non-cholesterol sterol biomarkers - such as cholesterol precursor sterols, plant sterols, and cholestanol - may help with the comprehensive assessment of cholesterol metabolism. An adequate cholesterol supply is essential for liver-regenerative capacity. Low preoperative and perioperative serum cholesterol levels seem to predict mortality in liver cirrhosis and after liver transplantation. Thus, accurate lipid profile evaluation is highly important in liver disease and after liver transplantation.
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Leung-Pineda V, Wilson DP. Severe Hypercholesterolemia and Cutaneous Xanthomas in a 3-Year-Old Boy. Clin Chem 2016; 62:899-900. [PMID: 27235469 DOI: 10.1373/clinchem.2015.250431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/10/2015] [Indexed: 11/06/2022]
Affiliation(s)
| | - Don P Wilson
- Department of Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX
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Chow A, Rifici VA, Schneider SH. Lipoprotein-X in a Patient with Lymphoplasmacytic Sclerosing Cholangitis: An Unusual Cause of Secondary Hypercholesterolemia. AACE Clin Case Rep 2016. [DOI: 10.4158/ep14249.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Affiliation(s)
- Midhat S Farooqi
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
| | - Ibrahim A Hashim
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
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Matsushima K, Sugiuchi H, Anraku K, Nishimura H, Manabe M, Ikeda K, Ando Y, Kondo Y, Ishitsuka Y, Irikura M, Irie T. Differences in reaction specificity toward lipoprotein X and abnormal LDL among 6 homogeneous assays for LDL-cholesterol. Clin Chim Acta 2015; 439:29-37. [DOI: 10.1016/j.cca.2014.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 09/25/2014] [Accepted: 09/25/2014] [Indexed: 11/28/2022]
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Knapper S, Chevassut T, Duarte R, Bergua JM, Salamero O, Johansen M, Jacobsen TF, Hals PA, Rasch W, Gianella-Borradori A, Smith M. Elacytarabine in relapsed/refractory acute myeloid leukaemia: an evaluation of clinical efficacy, pharmacokinetics, cardiac safety and effects on lipid profile. Leuk Res 2014; 38:346-51. [PMID: 24433865 DOI: 10.1016/j.leukres.2013.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/25/2022]
Abstract
Elacytarabine is the elaidic acid ester derivative of cytarabine, designed to enter cells independently of nucleoside transporters. Effects of elacytarabine on QT interval, serum lipid profile and clinical activity were investigated in 43 relapsed/refractory AML patients. Mean maximum increase in corrected QT interval of 24( ± 29)ms occurred 48 h after elacytarabine infusion without associated arrhythmias or clinical symptoms. A non-clinically significant, elacytarabine exposure-dependent increase in cholesterol was caused by a cholesterol rich lipoprotein depleted of apolipoprotein B formed by infused phospholipids complexing cholesterol. Elacytarabine is clinically active in relapsed/refractory AML: overall response rate (CR + CRi) was 44% (16/36 with 7 non-evaluable patients) and adverse events were manageable. Clinical Trials.gov Identifier: NCT01258816.
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Affiliation(s)
- Steven Knapper
- Department of Haematology, Cardiff University, Cardiff, UK.
| | | | | | | | - Olga Salamero
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Shanely RA, Nieman DC, Knab AM, Gillitt ND, Meaney MP, Jin F, Sha W, Cialdella-Kam L. Influence of vitamin D mushroom powder supplementation on exercise-induced muscle damage in vitamin D insufficient high school athletes. J Sports Sci 2013; 32:670-9. [DOI: 10.1080/02640414.2013.847279] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Miida T, Nishimura K, Okamura T, Hirayama S, Ohmura H, Yoshida H, Miyashita Y, Ai M, Tanaka A, Sumino H, Murakami M, Inoue I, Kayamori Y, Nakamura M, Nobori T, Miyazawa Y, Teramoto T, Yokoyama S. A multicenter study on the precision and accuracy of homogeneous assays for LDL-cholesterol: Comparison with a beta-quantification method using fresh serum obtained from non-diseased and diseased subjects. Atherosclerosis 2012; 225:208-15. [DOI: 10.1016/j.atherosclerosis.2012.08.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 08/09/2012] [Accepted: 08/16/2012] [Indexed: 10/28/2022]
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