Lipoprotein Apheresis (LDL/Lp(a) Apheresis) — Blood & Plasma Interventions
Extracorporeal removal of LDL and Lp(a) particles from blood — FDA-approved for familial hypercholesterolemia; reduces Lp(a) by 60-75% per session and cardiovascular events by ~35%.
Overview
Lipoprotein apheresis (LA) selectively removes apolipoprotein B-containing lipoproteins (LDL, Lp(a), VLDL, IDL) from the blood using affinity columns (heparin precipitation, dextran sulfate adsorption, or direct adsorption columns). Unlike statins, which only modestly reduce Lp(a) by 10-15%, LA reduces Lp(a) by 60-75% per session. The PRO:LiFE study demonstrated 35% reduction in major cardiovascular events with biweekly LA therapy in patients with progressive CVD and elevated Lp(a) despite maximum drug therapy. FDA cleared LA (Liposorber system) for homozygous familial hypercholesterolemia (HoFH) in 1996 and for hypercholesterolemia with coronary artery disease and LDL > 200 mg/dL despite maximum therapy in 1999. Medicare covers LA for these indications. Each session takes 2-3 hours biweekly. The upcoming RNA therapeutic pelacarsen (Novartis) and MK-0616 may provide ongoing Lp(a) reduction without apheresis — currently in Phase 3 trials.
Indications
- Homozygous familial hypercholesterolemia (HoFH) — LDL > 300-500 mg/dL despite maximum therapy
- Heterozygous FH with LDL > 200 mg/dL and progressive CVD despite maximum medical therapy
- Elevated Lp(a) > 60 nmol/L with progressive atherosclerosis despite statin + PCSK9 inhibitor therapy
- High cardiovascular risk patients with LDL-C or Lp(a) unable to be controlled with medications
Mechanism of Action
Patient blood passes through a column containing ligands (heparin, dextran sulfate, or polyacrylic acid beads) that selectively bind ApoB-containing lipoproteins — LDL, VLDL, IDL, and Lp(a) — which are then discarded
Dosing
| Compound | Dose | Frequency | Notes |
|---|---|---|---|
| Lipoprotein Apheresis (Liposorber or HELP system) | 1-1.5 blood volumes processed per session (typically 3-4L) | Every 1-2 weeks (biweekly is most common), ongoing | Reduces LDL by 60-75% per session; rebounds to ~50% of pre-session level by next week, requiring ongoing biweekly treatment |
Evidence Grade
GRADE A
Safety & Contraindications
- Hypotension during procedure (BP must be monitored continuously)
- ACE inhibitor hypersensitivity reactions (bradykinin accumulation) — hold ACE inhibitors 24 hours before procedure with dextran sulfate apheresis
- Heparin anticoagulation risks: bleeding, heparin-induced thrombocytopenia (HIT) — monitor platelets
- Large-bore IV access or AV fistula required for repeated procedures
- Fibrinogen and clotting factor reduction during procedure — monitor