LDL Apheresis and Lp (a) Apheresis: A Clinician's Perspective

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.

Keywords: Apheresis; Atherosclerosis; Familial hypercholesterolemia; Guidelines; Lipoprotein(a); Low-density lipoprotein cholesterol.

Fig. 1

Pictures present the regressed and completely vanished tendon xanthomas within the 2 years of effective LA therapy in a young patient with homozygous familial hypercholesterolemia. Tendon xanthomas on her right hand (A1) and feet (B1) before the initiation of apheresis when she was 22 years old. Completely vanished tendon xanthomas on her hand (A2) and feet (B2) after 2 years of regular weekly apheresis [^•]. Unfortunately, she was referred to apheresis more than 10 years after the initial symptoms of hypercholesterolemia. Although tendon xanthomas were regressed as a result of effective cholesterol reduction with regular apheresis, she died at the age of 27 years due to atherosclerotic complications of hypercholesterolemia. (With permission from: Kayikcioglu M et al. Turk Kardiyol Dern Ars. 2014;42:599–611. 10.5543/tkda.2014.09633) [^•]