Extracorporeal treatment of hypercholesterolaemia

Extracorporeal removal of LDL cholesterol (LDL apheresis) has been carried out in patients with diet- and drug-resistant hypercholesterolaemia to prevent or to reduce coronary heart disease. Plasma separation is the first step in all five LDL-apheresis methods presently available. Plain plasma exchange and double-membrane filtration are unselective and remove HDL cholesterol and plasma proteins. Adsorption of LDL to dextran sulphate, to LDL antibodies, or precipitation of LDL by heparin at low pH are more selective. With all methods LDL cholesterol reduction per treatment is 60-70%. In most patients one treatment per week is sufficient to reduce mean LDL to 100-150 mg/dl. Minor side-effects occur in 10 +/- 5% of treatments. Major side-effects are rare. Long-term LDL apheresis increased survival in patients with homozygous familial hypercholesterolaemia. In heterozygous familial hypercholesterolaemia controlled studies regarding survival are not available. Uncontrolled trials indicate regression of coronary artery disease in heterozygotes with drug- and diet-resistant LDL cholesterol > 200 mg/dl. Hence, LDL apheresis is indicated in all patients with homozygous familial hypercholesterolaemia. LDL apheresis in heterozygous familial hypercholesterolaemia should be restricted to patients with diet- and drug-resistant LDL cholesterol > 200 mg/dl with coronary heart disease and/or other atherosclerotic vascular lesion.