Cleaning out bad cholesterol
BACKGROUND: Cholesterol is a substance created and used by the human body to keep them healthy. There is ‘good’ cholesterol and ‘bad’ cholesterol, and too much of the bad cholesterol can increase a person’s risk for coronary heart disease, heart attack, or stroke. Cholesterol comes from the human body with the liver and other cells making around 75 percent of blood cholesterol, and the remaining 25 percent of cholesterol comes from food and is only found in animal products. The amount of cholesterol some people’s bodies make is affected by genetics, so family health history may be a good source to understand why someone’s cholesterol is at certain levels despite their lifestyle choices. (Source: American Heart Association)
TYPES: Often times the different types of cholesterol are simply referred to as ‘good’ cholesterol and ‘bad’ cholesterol. Below are descriptions and explanations of the two types of cholesterol:
· HDL (aka ‘good’ cholesterol) – HDL is considered the good cholesterol because it helps keep the ‘bad’ cholesterol from getting lodged into the artery walls, and a healthy HDL level may also prevent against heart attack or stroke. You can increase HDL levels with regular physical activity and by eating a balanced nutritious diet.
· LDL (aka ‘bad’ cholesterol) – LDL is considered the bad cholesterol because when there is too much of it circulating in the blood it can clog arteries, increasing the risk of heart attack and stroke. Eating saturated fat, trans fats, and dietary cholesterol can raise a person’s LDL levels, but LDL cholesterol is also produced by the body and inherited genes can make some people produce too much. (Source: American Heart Association)
TREATMENT: The first line of treatment for high cholesterol levels, especially high LDL levels, is lifestyle changes such as regularly exercising and limiting the amount of trans and saturated fats a person eats. However, some people will continue to struggle with high cholesterol even after making these lifestyle changes. For these people they may need to take cholesterol medications such as statins, which block a substance the liver needs to make cholesterol, cholesterol absorption inhibitors which limit the absorption of dietary cholesterol, and bile-acid-binding resins, which prompt the liver to use excess cholesterol to make more bile acids. (Source: Mayo Clinic)
LDL APHERESIS: LDL apheresis is a treatment for people with high LDL cholesterol levels who have been unable to lower their cholesterol through diet changes and exercise. The LDL apheresis procedure is similar to kidney dialysis in that the patient’s blood is continually removed and run through a machine that separates plasma. While the blood is returned to the patient through a different vein, the plasma is run through another part of the machine that removes the LDL. The procedure takes about 2 to 3 hours and must be repeated every 2 to 3 weeks. (Source: www.cedars-sinai.edu)
Amber Sanchez, M.D., in the Division of Nephrology and Hypertension, Associate Medical Director of the Apheresis Program at UC San Diego, talks about a new way to help people clean out their systems of bad cholesterol.
What is LDL?
Dr. Sanchez: LDL is the body’s bad cholesterol.
How do you get it?
Dr. Sanchez: The liver makes all of your cholesterol, both good and bad.
Is it too much of the wrong foods? Is it genetic?
Dr. Sanchez: So, having high cholesterol is a combination of factors including both genetic risk factors as well as unhealthy diet choices.
For most people statins do the trick, correct?
Dr. Sanchez: Most people who have high cholesterol can be managed with a combination of dietary changes and medications such as the statins.
But then for a select few, the statins and the diet changes just don’t work?
Dr. Sanchez: There are certain people who either the statins or dietary changes will not bring the cholesterol down far enough or they have intolerable side effects due to the medications.
What could some of those side effects be?
Dr. Sanchez: Side effects of the medications include severe muscle pains, a dangerous condition called rhabdomyolysis, liver toxicity.
If your LDL is high and you can’t control it, what is the risk?
Dr. Sanchez: It has been well established that a high LDL level is associated with increased risk factors for heart attacks, cardiovascular disease, strokes. Bringing it down by any means possible reduces that risk.
What is your risk if you can’t bring it down? If you have 5 or 10 years of bad LDL?
Dr. Sanchez: Having a high LDL places people more at risk for heart disease and plaque buildup in the arteries which can lead to a heart attack or a stroke.
What is a normal level for LDL? What is the worst LDL you have ever seen?
Dr. Sanchez: In general, if people don’t have risk factors, the goal LDL would be less than 160. If someone actually has heart disease then the goal is less than 70 for an LDL. For people who qualify for this procedure, their LDLs are in the 200 to 300 or even higher range.
What is the highest you have personally seen?
Dr. Sanchez: In the 300s.
Was that a shock for you?
Dr. Sanchez: Well, it is very high. This procedure is specifically for those people; people who have severely high cholesterol. Probably most of these people have genetic risk factors for high cholesterol and the medications that are available aren’t going to bring it down enough to reduce their risk for heart disease.
Without apheresis, what would happen to these people?
Dr. Sanchez: Without this procedure, most likely their coronary disease would worsen over time and they are more at risk for more heart attacks.
What is LDL apheresis?
Dr. Sanchez: LDL apheresis is a procedure that is performed about once every 2 weeks. Usually it is done with peripheral IVs placed in the arms. The blood exits the body, goes through a filter that separates the plasma from the blood which is the part of the blood that contains all the cholesterol. The plasma portion is then run through a special filter that just absorbs bad cholesterol and returns all the good cholesterol, all the other plasma proteins back to the patient.
Is this like dialysis for the blood?
Dr. Sanchez: It is similar to dialysis in that it is a process that cleans the blood. However, it only has to be done once every 2 weeks. If someone can be on cholesterol medications and continues a healthy lifestyle and diet, they can spread the treatments out further. It is considered a lifelong therapy unless new medications are available that could treat their cholesterol appropriately and that could be tolerated by the patient who is intolerant to current medications.
How long do they have to stay on the IV each time?
Dr. Sanchez: A typical procedure lasts about 3 to 4 hours.
From that fresh start, if you ate healthy, exercised, would you LDL shoot back up?
Dr. Sanchez: What happens is with one procedure the cholesterol will go down 70 to 80%, but then after you leave your liver continues to make cholesterol on a daily basis. So in those 2 weeks, even if at the end of the treatment you leave with LDL cholesterol of 60, in 2 weeks it might be back up into the 200s. So it is important that patients who do this procedure keep coming regularly, keep a healthy diet, and keep taking medications if they can tolerate them.
They are still going to creep up to 300 LDL?
Dr. Sanchez: Yes. For people who are genetically predisposed to high LDL cholesterol, the liver will continue to generate. For many of them, the problem is that the body is just not clearing the LDL cholesterol that the body is making.
What is the average age they first come to you?
Dr. Sanchez: We have been referred patients as young as 15 and as old as 74.
Now for those ones who are 74, have they always had this problem because their livers have always made it or is it something that gets worse over time?
Dr. Sanchez: Most people that qualify for this procedure are people that have had long-standing high cholesterol.
How long has this been around and have they just never been to a facility that had this?
Dr. Sanchez: There have been procedures available to reduce cholesterol since the early 70s. However, most of them have been very nonspecific and remove all of the plasma proteins not just the bad cholesterol. The type of LDL apheresis that we perform just removes the bad cholesterol, returning the good cholesterol to the patient. Now this technology has been available since the 80s, but only FDA approved since the 1990s. The reason that it has been an exciting procedure is that there are not many centers in the US that have the nurses and physicians who are trained in how to provide this procedure for patients. There are currently only about 60 centers in the US who perform LDL apheresis at all. So there are many patients who don’t live near a center, many cities that don’t have this technology available, and it is something that is an important complement to treating a patient with heart disease and with high cholesterol.
How long has Sandra been doing this and when you first saw her, what was she like?
Dr. Sanchez: I first met Ms. Miller about 6 months ago and I remember her story very clearly because she had had a cardiac catheterization probably in the 90s and she had known that she had high cholesterol all her life. When she had this cardiac catheterization, she was actually told she had a clean bill of health and everything looked great. So, she stopped worrying about her high cholesterol. She had tried diet all her life to reduce her cholesterol, she had also tried every single medication on the market but had not tolerated the side effects of the medications. Then a few years ago, she had her first heart attack. She had gotten a false sense of security by her negative catheterization years ago and during this time, cholesterol is building up in her arteries. So she is someone that this procedure is really important for because it is going to help prevent her heart disease from getting worse and perhaps reverse some of the plaque buildup that is already in her heart.
Do you remember the number that she came in with and what she leaves with after her procedure?
Dr. Sanchez: Her LDL when she started the procedure was in the 300s and at the end of each procedure her LDL is less than 70, which is her goal for having heart disease. She comes every 2 weeks and after 2 weeks her cholesterol is back up in the 200s.
Can you tell a difference physically when they come in and after?
Dr. Sanchez: Most people can’t feel high cholesterol. There are some studies that have shown that doing LDL apheresis will increase ability to do special exercise tests.
Is there any risk to this?
Dr. Sanchez: It is a procedure and so there are some risks associated. Overall it is well tolerated, but the most common side effect would be low blood pressure.
Is it worth the trouble if it is just going to spike back up?
Dr. Sanchez: Even though the liver will continue to generate cholesterol and after a procedure the cholesterol will be low but then in 2 weeks it will be high, over time the average cholesterol level will be low. We know that anything that can bring LDL cholesterol down is beneficial to the heart no matter how you bring it down; whether it is with diet, medications, or this procedure.
FOR MORE INFORMATION, PLEASE CONTACT:
Amber Sanchez, MD
The UCSD Apheresis Unit number: (619)543-5977
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