Practical aspects of direct adsorption of lipoproteins from whole blood by DALI LDL-apheresis.

Direct adsorption of lipoproteins (DALI) from whole blood is the first LDL-hemoperfusion procedure. The present paper addresses practical questions of DALI apheresis in order to optimise DALI therapy in sometimes critically ill coronary patients. The reduction of LDL and Lp(a) by DALI can be optimised by increasing the treated blood volume and the DALI adsorber volume. Hypotension (1.2% of sessions) may be minimised by fluid intake before the session, isovolemic connection of the patient to the ECC, reduced blood flow and low ACD-A ratio. Hypocalcemia may be avoided by low citrate anticoagulation (1:40) and reduced blood flow. Bradykinin release peaks at ca. 1000 ml of treated blood volume and may cause Quincke edema (tight throat), hypotension and flush. Reduction of the blood flow rate and decrease of citrate admixture as well as administration of iv. calcium may be helpful. While ACE inhibitors are contraindicated in DALI patients, sartans may be used without problems. Some "intrinsic" PTT increase is caused by adsorption of coagulation factors; undue PTT prolongations after DALI may be avoided by reduction of the heparin dosage during priming and treatment. In patients prone to alkalosis and hypokalemia, a reduction of the ACD-A ratio is recommended. Rises of adsorber inlet pressure may be due to insufficient anticoagulation and adsorber clotting or malfunctioning of the venous access. Rinsing of the adsorber with saline, administration of a heparin bolus and increase of the citrate admixture as well as a rinse and/or repositioning of the venous access are helpful measures. If these basic rules are followed, DALI LDL-apheresis is a safe, efficient, rapid and user-friendly LDL-apheresis procedure as evidenced by more than 80,000 DALI sessions successfully performed to date.