Apheresis for severe hypercholesterolaemia and elevated lipoprotein(a)

Low-density lipoprotein (LDL)-cholesterol (LDL-c) and lipoprotein(a) [Lp(a)] are independent cardiovascular risk factors. Reduction of LDL-c leads to reduction in cardiovascular events, regardless of the method of reducing LDL-c levels. Lifestyle modification and drugs are first line treatment options. However, many patients do not reach treatment goals, as defined in guidelines worldwide, through standard medication. So far, drugs are not efficient in lowering Lp(a) levels, or the reduction of plasma levels does not result in clinical benefit. In these two groups of patients lipoprotein apheresis is very efficient in decreasing LDL-c and Lp(a) levels. A single apheresis session can decrease LDL-c and Lp(a) by approximately 65%, and apheresis performed weekly or biweekly results in considerably decreased mean interval concentrations (approximately 30% reduction). Most apheresis systems (HELP, heparin induced extracorporeal LDL precipitation; DALI, direct adsorption of lipoproteins; lipoprotein apheresis with dextran sulfate; lipid filtration; immunoadsorption) decrease LDL-c and Lp(a). Lipopac is a specific form of immunapheresis and only decreases Lp(a). Lipoprotein apheresis is a well-tolerated treatment option but it is expensive and time consuming. The evidence for clinical benefit through regular apheresis comes from observational data. Adequate, randomised, controlled trials are lacking.