LIPID APHERESIS - FROM A HEROIC TREATMENT TO ROUTINE CLINICAL-PRACTICE

Lipid apheresis has developed from a heroic treatment into a routine c linical therapy and currently is the major indication for performing e xtracorporeal plasma therapy. Whereas it was once reserved for patient s with homozygous familial hypercholesterolemia, today it has a place in the secondary prevention of severe coronary heart disease when low- density lipoprotein (LDL)-cholesterol levels exceed 150 mg/dl, despite conservative treatment, in any type of primary hypercholesterolemia. Unselective plasma exchange has been replaced by a variety of selectiv e procedures. The efficacy of the treatment can be maximized by combin ing LDL apheresis with the use of cholesterol synthesis enzyme inhibit ors. Clinical studies have shown that drastic cholesterol reduction ca n result in regression of coronary atherosclerosis as well as in reduc ed cardiac morbidity and mortality. Technical progress comprises impro ved selectivity, online regeneration of adsorbers, and LDL adsorption from whole blood. Recently, a new LDL hemoperfusion procedure was succ essfully tested in a clinical pilot study; blood is passed directly ov er a lipid sorbent without prior plasma separation. If this system is demonstrated to be safe and effective in clinical Phase III trials, a further qualitative step in the rapid development of LDL apheresis wil l have been made.