LDL apheresis


Low density lipoprotein apheresis is used in the treatment of severe familial hypercholesterolemia and advanced coronary heart disease.
 
Incidence
Uncommon.
 
Temporary hypotension: 1%.
 
Risk factors
Concomitant use of ACE inhibitors.
 
Clinical manifestations
General: hypotension, bradycardia.
 
Cutaneous: flushing, facial edema.
 
Respiratory: dyspnea.
 
Digestive: nausea, abdominal pain.
 
Mechanisms
Because of its strong negative charges, dextran sulphate is a potent activator of the contact activation system (Hageman factor, high molecular weight kininogen, prekallikrein, coagulation factor XI).
 
Kallikrein generates bradykinin from high molecular weight kininogen. LDL apheresis with dextran sulphate is associated with increased bradykinin generation. Bradykinin catabolism is decreased by ACE inhibitors. Bradykinin is a potent vasodilator and smooth muscle constrictor in bronchi and intestine.
 
Management
Withdraw captopril 24 hours before treatment.
 
No reaction is observed when futhan is used instead of heparin (protease inhibitory activity of futhan).

References

  1. Schwarzbeck A, Hilgenfeldt U, Riester U, Rambausek M, Kiral A, "Anaphylacotid reactions during dextran apheresis may occur even in the absence of ACE-inhibitor administration", Nephrol. Dial. Transplant., 1997; 12 (5): 1083-4
  2. Koga N, Nagano T, Sato T, Kagasawa K, "Anaphylactoid reactions and bradykinin generation in patients treated with LDL-apheresis and an ACE inhibitor", ASAIO J, 1993; 39 (3): M288-91
  3. Keller C, Grutzmacher P, Bahr F, Schwarzbeck A, Kroon A.A, Kiral A, "LDL-apheresis with dextran sulphate and anaphylactoid reactions to ACE inhibitors", Lancet, 1993; 341 (8836): 60-1
  4. Kroon A.A, Mol M.J, Stalenhoef A.F, "ACE inhibitors and LDL-apheresis with dextran sulphate adsorption", Lancet., 1992; 340 (8833): 1476
  5. Olbricht C.J, Schaumann D, Fischer D, "Anaphylactoid reactions, LDL apheresis with dextran sulphate, and ACE inhibitors", Lancet, 1992; 340 (8824): 908-9

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.