During the last decades,
LDL-
apheresis was established as an extracorporeal treatment option for patients with severe heterozygous or
homozygous familial hypercholesterolemia (FH) that is resistant to conventional treatment strategies such as diet, drugs, and changes in lifestyle. Nearly half a century ago, the first
LDL-
apheresis treatment was performed by
plasma exchange in a child with homozygous FH. At the beginning of the 1970s, the clinical advantage of regular extracorporeal
LDL-elimination was demonstrated in siblings suffering from homozygous FH. These findings encouraged researchers especially from Germany and Japan to develop extracorporeal devices to selectively eliminate
LDL-cholesterol in the 1980s. Although the selectivity of the currently available
LDL-
apheresis devices is different, the efficacy of
LDL-elimination during a single treatment is rather similar and ranges between 55 and 65 % of the pretreatment
LDL plasma concentration.In the 1990s, the patients regularly treated by extracorporeal
LDL-elimination, diet, and drugs were included in regression studies assessed by angiography. It was shown that the combined treatment with
LDL-
apheresis, diet, and drugs resulted in less progression of coronary lesions than drugs and/or diet alone. However, although a tendency was evident, results did not reach criteria for significance. During the last decade,
apheresis registries were established to collect data on efficiency, safety, and clinical outcome of regular long-term
LDL-
apheresis. The evaluation of registry data will certainly permit further insights in the therapeutic benefit of this expensive and time-consuming therapeutic approach. Furthermore, the future of
LDL-
apheresis will depend upon the availability of highly efficient new drugs and molecular genetic approaches such as RNA silencing of the
apoB gene, whereas the
liver transplantation and gene therapy of the
LDL-receptor deficiency will not replace
LDL-
apheresis in severe
familial hypercholesterolemia in the near future.