Combined Treatment With Lipoprotein Apheresis and Hemodialysis in Patients With Severe Cardiovascular Disease, High Lipoprotein(a) and End Stage Renal Disease

Abstract

Elevated Lipoprotein(a) (Lp(a)) is a known independent cardiovascular risk factor. Lp(a) Lipoprotein Apheresis (LA) substantially reduces the number of cardiovascular events. The effect of LA treatment in hemodialysis (HD) patients remains unknown. Retrospective analysis of nine patients undergoing LA and HD. Cardiovascular risk factors and the efficacy of treatment were assessed. Adverse cardiac or vascular events (ACVE) were recorded. Median (range) years on HD were 4.2 (1.5 to 23.6) years and median years on LA were 4.0 (1.6 to 12.4) years. Before initiation of LA, median (range) Lp(a) level was 242.67 (164.0 to 400.10) nmol/L and mean LDL-C level (±SD) 2.49 (±1.14) mmol/L. Under treatment, mean acute reduction rates, comparing concentrations before and after LA sessions, were 64.15 (±5.45)% for Lp(a) and 57.26 (±7.93)% for LDL-C. Before initiation of LA, 14 ACVE occurred; after initiation, only 6 (57.2% reduction rate). In this small cohort, LA appears to be effective in reducing ACVE in patients on HD with elevated Lp(a) levels. Further studies are needed to evaluate the effect of LA on cardiovascular outcomes in dialysis patients.

Keywords: ACVE; dialysis; lipid disorder; lipoprotein apheresis; lipoprotein(a).

FIGURE 1

Treatment protocols of combined hemodialysis (HD) and Lipoprotein Apheresis (LA) treatment. All patients were treated thrice weekly by HD (red lines) and one (orange line) to two times weekly (dotted orange line indicates alternative or second treatment per week) by LA. (A) Two of nine patients were treated sequentially with one patient having HD and LA consecutively on the same day and one patient having HD 1 day and LA the next day. (B) All other patients were treated in parallel with HD and LA at the same time. In case of LA once weekly, LA and HD were combined on Wednesday. In case of two LA treatments per week, HD and LA were conducted on Monday and Friday.

FIGURE 2

Example of combined hemodialysis (HD) and lipoprotein apheresis (LA) treatment. 15G needles are placed in the forearm fistula of the patient (A). Blood flow is split up by a Y‐piece (B) leading one part of the blood to the LA machine (C, Doublefiltration Fresenius MONET) and one part to the hemodialysis machine (D, Nikkiso DBB07). In parallel, back flow of the blood is conducted via another Y‐piece, and the cleared blood goes back to the patient (A, B).

FIGURE 3

Cumulated number of adverse cardiac or vascular events (ACVE) per year before and after initiation of lipoprotein apheresis (LA). In the 3 years before initiation of LA in total of 14 ACVE occurred in nine patients, whereas in the 4 years after initiation of LA, only six ACVE were recorded (n = 9 first year, n = 8 year 2–3 and n = 5 in the 4th year). This difference in ACVE before and after initiation of LA is statistically significant (p = 0.018) suggesting the efficacy of LA treatment in reducing ACVE in hemodialysis patients.