Note: Descriptions are shown in the official language in which they were submitted.
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METHODS FOR PROPHYLACTICALLY PREVENTING, SLOWING THE
PROGRESSION OF, OR TREATING ALZHEIMER'S DISEASE
CROSS-REFERENCE
The present application relies on United States Provisional Patent Application
Number
62/465,262, entitled "Method for Treating Familial Hypercholesterolemia" and
filed on March 1,
2017, for priority.
The present application is a continuation-in-part of United States Patent
Application
Number 15/876,808, entitled "Methods for Treating Cholesterol-Related
Diseases", and filed on
January 22, 2018, which, in turn, relies on United States Provisional Patent
Application Number
62/449,416, entitled "Method for Treating Familial Hypercholesterolemia" and
filed on January
23, 2017, for priority.
The present application relies on United States Provisional Patent Application
Number
62/516,100, entitled "Methods for Treating Cholesterol-Related Diseases" and
filed on June 6,
2017, for priority.
The present application relies on United States Provisional Patent Application
Number
62/537,581, entitled "Methods for Treating Cholesterol-Related Diseases" and
filed on July 27,
2017, for priority.
The above-mentioned applications are all incorporated herein by reference in
their entirety.
FIELD
The method of the present specification provides for successively repeated
treatment
procedure for selective removal of lipid from HDL to create a modified HDL
particle while leaving
LDL particles substantially intact and the administration of the modified HDL
particle to an
individual having Alzheimer's disease in order to delay, halt and stabilize,
reverse or improve the
progression of the disease or pathophysiologic process that leads to the
symptoms related to
Alzheimer' s disease.
BACKGROUND
Historically, the use of clinical criteria that defined later stages of
Alzheimer's disease
(AD), such as after the onset of severe and marked dementia, determined the
patients that were
enrolled in clinical trials exhibited both the cognitive changes typical of
clinically evident AD and
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the degree of functional impairment associated with marked dementia. As the
scientific
understanding of AD has evolved, efforts have been made to incorporate
additional diagnostic
information in order to enroll a greater class of patients in clinical trials.
This diagnostic
information includes, to varying degrees, the use of biomarkers reflecting
underlying
pathophysiological changes, which allows for the enrollment of patients in
which there may be no
apparent functional impairment or no detectable clinical abnormality. These
patients are
categorized as early onset AD patients. In using a broader range of diagnostic
information to
assess the degree and extent of AD, it is possible to intervene much earlier
in the disease process
given the onset of pathophysiological changes that can be measured and that
precede clinically
evident findings. There is thus a need to delay, halt, and preferably reverse
the pathophysiological
process that leads to the initial clinical deficits presented by AD.
AD is determined using results from several tests to arrive at a differential
diagnosis. Thus,
there is no definitive diagnosis for AD. Research has indicated that familial
hypercholesterolemia
is an early risk factor for AD. It is theorized that LDL receptors are
involved in increasing the risk
of AD. It has been observed that certain individuals are predisposed to AD, as
demonstrated by
family history or by genetic testing. Given that there is no established
treatment for AD once
lesions are formed, it would be desirable to provide a prophylactic way to
treat AD or prevent the
onset of AD altogether.
Existing apheresis and extracorporeal systems for treatment of plasma
constituents and
therefore lipid-related diseases suffer from a number of disadvantages that
limit their ability to be
used in clinical applications. A need exists for improved systems, apparatuses
and methods
capable of removing lipids from blood components in order to provide
treatments and preventative
measures for AD.
While the methods to selectively delipidate HDL particles overcomes several of
the
limitations stated above, what is also needed is a method to selectively
remove lipid from HDL
particles and thereby create modified HDL particles with increased capacity to
accept cholesterol,
without substantially affecting LDL particles, in chronic diseases. What is
also needed is a method
to successively monitor effectiveness of the modified HDL particles in
accepting cholesterol in
order to monitor the progress of a treatment using imaging techniques such as
CT Angiography.
Additionally, what is needed is a method to treat AD or prevent the onset of
AD.
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SUMMARY
The following embodiments and aspects thereof are described and illustrated in
conjunction
with systems, tools and methods, which are meant to be exemplary and
illustrative, not limiting in
scope.
In some embodiments, the present specification discloses a method for delaying
a
progression of, halting and stabilizing, or reversing and improving symptoms
related to
Alzheimer's Disease (AD) in a patient, comprising: monitoring a
pathophysiological change
indicative of AD in a patient; based on said monitoring, determining if
amyloid plaque is present
in a perivascular space of the patient; determining an extent of amyloid
plaque in said perivascular
space; and, based on the presence of amyloid plaque in the perivascular space
of the patient,
determining a treatment protocol for the patient, wherein the treatment
protocol comprises
administering to the patient a high density lipoprotein composition derived
from mixing a blood
fraction with a lipid removing agent.
Optionally, diagnostic imaging is used to determine the presence and extent of
amyloid
plaque in the perivascular space of the patient.
Optionally, the high density lipoprotein composition is derived by obtaining
the blood
fraction from the patient, wherein the blood fraction has high-density
lipoproteins; mixing the
blood fraction with the lipid removing agent to yield modified high-density
lipoproteins;
separating the modified high-density lipoproteins; and delivering the modified
high-density
lipoproteins to the patient.
Optionally, the method further comprises connecting the patient to a device
for withdrawing
blood; withdrawing blood from the patient; and separating blood cells from the
blood to yield the
blood fraction containing high density lipoproteins and low density
lipoproteins.
Optionally, the modified high density lipoproteins have an increased
concentration of pre-
beta high density lipoproteins relative to the high density lipoproteins from
the blood fraction prior
to mixing.
Optionally, the pathophysiological change is indicated by an accumulation of
plaque in the
perivascular space of the patient resulting in cerebral amyloid angiopathy.
Optionally, the high density lipoprotein composition derived from mixing the
blood
fraction with the lipid removing agent is delivered to the patient via
infusion therapy in a dosage
ranging from 1 mg/kg to 250 mg/kg.
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Optionally, the high density lipoprotein composition derived from mixing the
blood
fraction of the patient with the lipid removing agent is delivered to the
patient via infusion therapy
at a rate of 999 mL/hour or another rate determined best for the patient.
Optionally, the method further comprises determining a severity of AD in the
patient using
at least one of global functioning, cognitive functioning, activities of daily
living, or behavioral
assessments.
Optionally, after administering to the patient the high density lipoprotein
composition, the
patient experiences a halt in further accumulation or a decrease in the
accumulation of amyloid
plaque in the perivascular space.
Optionally, after administering to the patient the high density lipoprotein
composition, a
rate of degeneration of the patient's physiological and/or cognitive
parameters indicative of AD
stabilizes and does not experience a further decrease.
Optionally, after administering to the patient the high density lipoprotein
composition, a
rate of degeneration of the patient's physiological and/or cognitive
parameters indicative of AD,
slows down relative to a rate of degeneration of the patient's physiological
and/or cognitive
parameters indicative of AD before administering to the patient the high
density lipoprotein
composition.
Optionally, after administering to the patient the high density lipoprotein
composition, the
patient's physiological and/or cognitive symptoms indicative of AD improve
relative to the
patient's physiological and/or cognitive symptoms indicative of AD before
administering to the
patient the high density lipoprotein composition.
Optionally, the high density lipoprotein composition is derived by obtaining
the blood
fraction from an individual other than the patient, wherein the blood fraction
has high-density
lipoproteins; mixing the blood fraction with the lipid removing agent to yield
modified high-
density lipoproteins; separating the modified high-density lipoproteins; and
delivering the
modified high-density lipoproteins to the patient.
In some embodiments, the present specification discloses a method for delaying
the
progression of, halting and stabilizing, or reversing and improving symptoms
related to
Alzheimer's Disease (AD) in a patient, comprising: monitoring a
pathophysiological change
indicative of AD, or a potential future onset of AD, in the patient; based on
said monitoring,
determining if amyloid plaque is present in a perivascular space of the
patient; based on the
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determination of the presence of amyloid plaque in the perivascular space of
the patient,
determining a treatment protocol for the patient, wherein the treatment
protocol comprises
administering to the patient a high density lipoprotein composition derived
from mixing a blood
fraction, having unmodified high density lipoproteins, with a lipid removing
agent to yield
modified high density lipoproteins, wherein the modified high density
lipoproteins have an
increased concentration of pre-beta high density lipoprotein relative to the
unmodified high density
lipoproteins.
Optionally, the composition is derived by obtaining the blood fraction from
the patient;
mixing the blood fraction with the lipid removing agent to yield the modified
high-density
lipoproteins; separating the modified high-density lipoproteins; and
delivering the modified high-
density lipoproteins to the patient.
Optionally, the method further comprises connecting the patient to a device
for withdrawing
blood; withdrawing blood from the patient; and separating blood cells from the
blood to yield the
blood fraction containing low density lipoproteins and the high density
lipoproteins.
Optionally, the composition is derived by obtaining the blood fraction from an
individual
other than the patient; mixing the blood fraction with the lipid removing
agent to yield the modified
high-density lipoproteins; separating the modified high-density lipoproteins;
and delivering the
modified high-density lipoproteins to the patient.
In some embodiments, the present specification discloses a method for
improving an
impairment of cognitive function indicative of Alzheimer's Disease (AD) in a
patient, comprising:
determining if amyloid plaque is present in a perivascular space of the
patient; determining an
extent or severity of cognitive impairment in the patient using at least one
of a global, cognitive,
functional or behavioral assessment test; and, based on the determination of
the presence of
amyloid plaque in the perivascular space of the patient and said extent or
severity of cognitive
impairment in the patient, determining a treatment protocol for the patient,
wherein the treatment
protocol comprises administering to the patient a high density lipoprotein
composition derived
from mixing a blood fraction of the patient with a lipid removing agent.
Optionally, the method further comprises determining an extent of amyloid
plaque in the
perivascular space and determining the treatment protocol based at least in
part on the determined
extent of amyloid plaque.
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Optionally, the modified high density lipoproteins have an increased
concentration of pre-
beta high density lipoprotein relative to high density lipoproteins from the
blood fraction prior to
mixing.
Optionally, the composition is derived by: obtaining the blood fraction from
the patient;
mixing said blood fraction with the lipid removing agent to yield modified
high-density
lipoproteins; separating said modified high-density lipoproteins; and
delivering said modified
high-density lipoproteins to said patient.
Optionally, the AD is indicated by at least one of homozygous familial
hyp erchol e sterol emi a, heterozygous familial hyp erchol e sterol emi a, i
schemic stroke, coronary
artery disease, acute coronary syndrome, or peripheral arterial disease.
Optionally, periodically monitoring changes comprises monitoring changes
within a period
of three to six months.
Optionally, the mixing the blood fraction with a lipid removing agent yields
modified high
density lipoprotein that has an increased concentration of pre-beta high
density lipoprotein relative
to total protein.
The aforementioned and other embodiments of the present specification shall be
described
in greater depth in the drawings and detailed description provided below.
BRIEF DESCRIPTION OF THE DRAWINGS
These and other features and advantages of the present specification will be
appreciated,
as they become better understood by reference to the following detailed
description when
considered in connection with the accompanying drawings, wherein:
FIG. 1A is a flow chart delineating the steps of treating cardiovascular
diseases using the
treatment systems and methods in accordance with embodiments of the present
specification;
FIG. 1B is another flow chart delineating the steps of treating cholesterol-
related diseases,
such as Atheroembolic Renal Disease (AERD), using the treatment systems and
methods in
accordance with embodiments of the present specification;
FIG. 1C is a table illustrating the types of treatments that may be provided
for different
compositions of degenerative material determined from an analysis, in
accordance with some
embodiments of the present specification;
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FIG. 2 is a schematic representation of a plurality of components used in
accordance with
some embodiments of the present specification to achieve the processes
disclosed herein;
FIG. 3 is a pictorial illustration of an exemplary embodiment of a
configuration of a
plurality of components used in accordance with some embodiments of the
present specification
to achieve the processes disclosed herein;
FIG. 4 is a longitudinal transverse cross-sectional view of a cerebral blood
vessel
illustrating removal of beta amyloid by transport along a cerebral lymphatic
perivascular pathway,
in accordance with an embodiment of the present specification;
FIG. 5 is a longitudinal transverse cross-sectional view of a cerebral blood
vessel
illustrating amyloid accumulation in a cerebral lymphatic perivascular pathway
of an individual
having a high level of the e4 allele, in accordance with an embodiment of the
present specification;
FIG. 6A is a longitudinal transverse cross-sectional view of a cerebral blood
vessel of an
AD patient being treated for cerebral amyloid angiopathy (CAA), in accordance
with an
embodiment of the present specification;
FIG. 6B illustrates a mechanism of removal of beta amyloid molecules by
infusing pre-0
HDL particles within the blood vessel of FIG. 6A, in accordance with an
embodiment of the
present specification;
FIG. 6C shows modified pre-0 HDL particles flowing through the blood stream of
the
blood vessel of FIG. 6A, in accordance with an embodiment of the present
specification; and
FIG. 7 is a flowchart describing plurality of exemplary steps of a therapeutic
protocol for
treating an AD patient, in accordance with an embodiment of the present
specification.
DETAILED DESCRIPTION
The present specification relates to methods and systems for treating
cholesterol-related
diseases. Embodiments of the present specification monitor changes in one or
more atheroma
areas and volumes in a patient, regularly over a period of time. Atheroma
areas and volumes are
monitored using known imaging techniques, for lipid-containing degenerative
material in stenosis.
In accordance with embodiments of the present specification, based on the
results of the
monitoring, treatment is provided if accumulated lipid-containing degenerative
material is
identified to be present and above a threshold value. The treatment is
repeated each time the
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atheroma areas and volumes are monitored, at pre-defined time intervals, and
accumulated lipid-
containing degenerative material is identified to be present and above the
threshold.
Embodiments of the present specification treat the condition through systems,
apparatuses
and methods useful for removing lipid from a-High Density Lipoprotein (a-HDL)
particles derived
primarily from plasma of the patient thereby creating modified HDL particles
with reduced lipid
content, particularly reduced cholesterol content. Embodiments of the present
specification create
these modified HDL particles with reduced lipid content without substantially
modifying LDL
particles. Embodiments of the present specification modify original a-HDL
particles to yield
modified HDL particles that have an increased concentration of pre-f3 HDL
relative to the original
HDL.
Further, the newly formed derivatives of HDL particles (modified HDL) are
administered
to the patient to enhance cellular cholesterol efflux and treat cardiovascular
diseases and/or other
lipid-associated diseases, including Atheroembolic Renal Disease (AERD). The
regular periodic
monitoring and treatment process renders the methods and systems of the
present specification
more effective in treating cardiovascular diseases including Homozygous
Familial
Hypercholesterolemia (HoFH), Heterozygous Familial Hypercholesterolemia
(HeFH), Ischemic
stroke, Coronary Artery Disease (CAD), Acute Coronary Syndrome (ACS),
peripheral arterial
disease (PAD), Renal Arterial Stenosis (RAS), and for treating the progression
of Alzheimer's
Disease.
The present specification is directed towards multiple embodiments. The
following
disclosure is provided in order to enable a person having ordinary skill in
the art to practice the
invention. Language used in this specification should not be interpreted as a
general disavowal of
any one specific embodiment or used to limit the claims beyond the meaning of
the terms used
therein. The general principles defined herein may be applied to other
embodiments and
applications without departing from the spirit and scope of the invention.
Also, the terminology
and phraseology used is for the purpose of describing exemplary embodiments
and should not be
considered limiting. Thus, the present invention is to be accorded the widest
scope encompassing
numerous alternatives, modifications and equivalents consistent with the
principles and features
disclosed. For purpose of clarity, details relating to technical material that
is known in the technical
fields related to the invention have not been described in detail so as not to
unnecessarily obscure
the present invention. In the description and claims of the application, each
of the words
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"comprise" "include" and "have", and forms thereof, are not necessarily
limited to members in a
list with which the words may be associated.
It should be noted herein that any feature or component described in
association with a
specific embodiment may be used and implemented with any other embodiment
unless clearly
indicated otherwise.
The term "fluid" may be defined as fluids from animals or humans that contain
lipids or
lipid containing particles, fluids from culturing tissues and cells that
contain lipids and fluids mixed
with lipid-containing cells. For purposes of this invention, decreasing the
amount of lipids in fluids
includes decreasing lipids in plasma and particles contained in plasma,
including but not limited
to HDL particles. Fluids include, but are not limited to: biological fluids;
such as blood, plasma,
serum, lymphatic fluid, cerebrospinal fluid, peritoneal fluid, pleural fluid,
pericardial fluid, various
fluids of the reproductive system including, but not limited to, semen,
ejaculatory fluids, follicular
fluid and amniotic fluid; cell culture reagents such as normal sera, fetal
calf serum or serum derived
from any animal or human; and immunological reagents, such as various
preparations of antibodies
and cytokines from culturing tissues and cells, fluids mixed with lipid-
containing cells, and fluids
containing lipid-containing organisms, such as a saline solution containing
lipid-containing
organisms. A preferred fluid treated with the methods of the present invention
is plasma.
The term "lipid" may be defined as any one or more of a group of fats or fat-
like substances
occurring in humans or animals. The fats or fat-like substances are
characterized by their
insolubility in water and solubility in organic solvents. The term "lipid" is
known to those of
ordinary skill in the art and includes, but is not limited to, complex lipid,
simple lipid, triglycerides,
fatty acids, glycerophospholipids (phospholipids), true fats such as esters of
fatty acids, glycerol,
cerebrosides, waxes, and sterols such as cholesterol and ergosterol.
The term "extraction solvent" or "lipid removing agent" may be defined as one
or more
solvents used for extracting lipids from a fluid or from particles within the
fluid. This solvent
enters the fluid and remains in the fluid until removed by other subsystems.
Suitable extraction
solvents include solvents that extract or dissolve lipid, including but not
limited to phenols,
hydrocarbons, amines, ethers, esters, alcohols, halohydrocarbons, halocarbons,
and combinations
thereof Examples of suitable extraction solvents are ethers, esters, alcohols,
halohydrocarbons,
or halocarbons which include, but are not limited to di-isopropyl ether
(DIPE), which is also
referred to as isopropyl ether, diethyl ether (DEE), which is also referred to
as ethyl ether, lower
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order alcohols such as butanol, especially n-butanol, ethyl acetate,
dichloromethane, chloroform,
isoflurane, sevoflurane (1,1, 1,3, 3,3- hexafluoro-2- (fluoromethoxy) propane-
d3),
perfluorocyclohexanes, trifluoroethane, cyclofluorohexanol, and combinations
thereof.
The term "patient" refers to animals and humans, which may be either a fluid
source to be
treated with the methods of the present invention or a recipient of
derivatives of HDL particles and
or plasma with reduced lipid content.
The term "HDL particles" encompasses several types of particles defined based
on a variety
of methods such as those that measure charge, density, size and immuno-
affinity, including but
not limited to electrophoretic mobility, ultracentrifugation, immunoreactivity
and other methods
known to one of ordinary skill in the art. Such HDL particles include but are
not limited to the
following: a-HDL, pre-0 HDL (including pre-01 HDL, pre-02 HDL and pre- 03HDL),
HDL2
(including HDL2a and HDL2b), HDL3, VHDL, LpA-I, LpA-II, LpA-I/LpA-II (for a
review see
Barrans et al. , Biochemica Biophysica Acta 1300 ; 73-85,1996). Accordingly,
practice of the
methods of the present invention creates modified HDL particles. These
modified derivatives of
HDL particles may be modified in numerous ways including but not limited to
changes in one or
more of the following metabolic and/or physico-chemical properties (for a
review see Barrans et
al., Biochemica Biophysica Acta 1300; 73-85,1996); molecular mass (kDa);
charge; diameter;
shape; density; hydration density; flotation characteristics; content of
cholesterol; content of free
cholesterol; content of esterified cholesterol; molar ratio of free
cholesterol to phospholipids;
immuno-affinity; content, activity or helicity of one or more of the following
enzymes or proteins:
ApoA-I, ApoA-II, ApoD, ApoE, ApoJ, ApoA-IV, cholesterol ester transfer protein
(CETP),
lecithin; cholesterol acyltransferase (LCAT); capacity and/or rate for
cholesterol binding, capacity
and/or rate for cholesterol transport.
The term "fractional flow reserve" or "FFR" is used to refer to a measurement
of pressure
differences across a coronary artery stenosis (a narrowing, usually due to
atherosclerosis) to
determine the likelihood that the stenosis impedes oxygen delivery to the
heart muscle. Fractional
flow reserve is defined as the pressure after (distal to) a stenosis relative
to the pressure before the
stenosis and is presented as an absolute number. An FFR value of 0.70 means
that a given stenosis
causes a 30% drop in blood pressure. Thus, FFR is used to express the maximal
flow down a
vessel in the presence of stenosis compared to the maximal flow in the
hypothetical absence of
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stenosis. A decrease in blood flow, which is measured in terms of blood
pressure using FFR,
results in a decrease in oxygen delivery via blood (blood oxygen delivery).
The term "blockage due to lipid content" is measured in a percentage and is
used to refer
to the extent of physical blockage in an artery.
Cardiovascular Diseases
FIG. lA is a flow chart illustrating an exemplary process of treating
cardiovascular diseases,
such as, but not limited to HoFH, HeFH, Ischemic stroke, CAD, ACS, peripheral
arterial disease
(PAD) and for treating the progression of Alzheimer's Disease in accordance
with some
embodiments of the present specification. At step 102, a subject or a patient
who is diagnosed
with a cardiovascular disease is monitored for one or more atheroma areas
and/or volumes via a
diagnostic procedure. In an embodiment, advanced medical imaging techniques,
such as, but not
limited to Computer Tomography (CT) angiogram and/or Intravascular Ultrasound
(IVUS), may
be used to detect areas within the inner layer of artery walls where lipid-
containing degenerative
material may have accumulated. Accumulated degenerative material may include
fatty deposits
which may include mostly macrophage cells, or debris, containing lipids,
calcium and a variable
amount of fibrous connective tissue. Analysis from the imaging techniques may
also be used to
identify and therefore monitor volumes of lipid-containing degenerative
material accumulated
within the inner layer of artery walls. Lipid-containing degenerative material
and non-lipid-
containing degenerative material may swell in the artery wall, thereby
intruding into the channel
of the artery and narrowing it, resulting in restriction of blood flow.
Based on analysis from the diagnostic technique, in step 104, the presence and
type of
degenerative material is confirmed. In addition, the extent or percentage
blockage caused by
degenerative material (lipid-containing or non-lipid-containing) is determined
by a physician using
diagnostic imaging techniques. If no degenerative material is detected at step
104, or if the level
of degenerative material falls outside a pre-determined range of values, the
process is stopped. In
an embodiment, the physician identifies one or more arteries with stenosis
that have a blockage of
20% - 70% due to accumulated lipids, in order to implement treatment methods
in accordance with
the present specification. In step 106, a Fractional Flow Reserve (FFR)
measurement is used to
determine the extent of oxygen delivery in the presence of stenosis. In an
embodiment, FFR is
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used to measure pressure differences across a coronary artery stenosis to
determine the likelihood
that the stenosis impedes blood oxygen delivery to the heart muscle
(ischemia).
Different types of treatments may be provided depending on the diagnostic
results and
threshold values. At this stage, the physician may determine that either the
treatment in accordance
with embodiments of the present specification is not required as the disease
has subsided, is not
present, is not sufficient, or has been treated, or an alternative form of
treatment (such as a physical
stent) is required.
FIG. 1C is a table illustrating the types of treatments that may be provided
for different
compositions of degenerative material determined from the diagnosis for
cardiovascular diseases,
as described in the flow chart of FIG. 1A, in accordance with some embodiments
of the present
specification. The table compares different types of treatments that may be
administered for
combinations of various ranges of a Fractional Flow Reserve (FFR) 402, which
is indicative of a
rate of flow of blood after a blockage (which, in turn, is indicative of blood
oxygen delivery),
provided in terms of percentage (or fraction) of Fractional Flow Reserve, and
various ranges of
physical blockage due to lipid content 404, provided in terms of percentage of
blockage due to
lipid content. Referring to the table, each cell, such as cells 406,
corresponds to a combination of
a range 402 (indicative of FFR) and a range 404 (indicative of the percentage
or extent of blockage
due to lipid content), which further indicates at least one method of
treatment that may be suitable
for that combination.
In embodiments, the different types of treatments are coded as A, B, C, and D.
Treatment
type 'A' corresponds to an invasive treatment process where a stent is
embedded through physical
intervention. Treatment type '13' corresponds to implementing the treatment
methods of
selectively modifying HDL particles, in accordance with the embodiments of the
present
specification. In an embodiment, it is preferable to selectively modify HDL
particles (and perform
the HDL infusions) where the Fractional Flow Reserve (FFR) ranges from 80-100%
and the
accumulated lipid obstruction ranges from 20-70%, as noted by sections 404. It
should be noted
herein that in embodiments, a FFR measurement of 1-79% represents an ischemic
condition,
wherein a FFR measurement of 80-100% represents a non-ischemic condition. In
most cases,
treatment types 'A' and/or '13' may be able to address the condition.
Treatment type `D'
corresponds to cases where neither of the stated treatment types (A and/or B)
is required. In some
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cells, such as cells 408, two treatment options may be indicated and the
physician would decide
upon the appropriate course of treatment.
Treatment type 'C' corresponds to cases where a combination of both a stent as
well as
selective modification of HDL particles is administered (as described in
greater detail below with
respect to 114a in FIG. 1A). Atherosclerosis is a systemic disease and
patients may have multiple
lesions throughout their vasculature. Therefore, it should be noted herein
that the treatment
methods of the present specification are not implemented based on an overall
patient health-based
treatment strategy, but rather a "lesion/plaque/area/region"-based treatment
strategy. Thus, in a
few cases, a physician may decide to combine the treatments and administer
treatment type 'C'.
If, in a particular patient, one or more areas or lesions have a FFR of 79% or
less (ranging from
1% to 79%), then those areas would have a stent implanted. If the same patient
presents with
additional, remaining lesions that exhibit lipid-based blockage in the range
of 20-70% and also an
FFR of 80-100%, then the patient would undergo a subsequent delipidation.
Therefore, both
interventions may be used for patients having multiple lesions with different
levels of disease at
each lesion.
Referring again to FIG. 1A, at step 108a, a physician determines whether the
amount of
accumulated lipid-containing degenerative material, covering a
lesion/plaque/area/region, falls
above a predetermined threshold value or within a range of values, as measured
in terms of a
percentage of blockage due to lipid content. If arteries with atheroma
lesion(s) having an amount
or volume of lipid-containing material above the threshold percentage value or
that fall within a
range of values are not identified, an alternative treatment process (which
may include no treatment
or physical intervention) is determined by the physician, in step 110b. If
arteries with lipid-
containing atheroma lesion/plaque/area/region(s) having an amount or volume of
lipid blockage
above the predetermined threshold percentage or within a predetermined range
of percentages are
identified, the patient is then subjected to the delipidation process, in step
110a. The delipidation
process of the present specification is described in greater detail below.
At step 108b, a physician determines whether, based on the FFR measurement,
blood
oxygen delivery is impeded below a threshold value or within a range of values
(which is expressed
as the maximal flow of blood down a vessel in the presence of stenosis
compared to the maximal
flow in the hypothetical absence of stenosis). If blood oxygen delivery is
impeded below a
threshold value or within a predetermined range of values, then in step 112a,
a physician treats
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with physical intervention, such as a stent. In step 112b, if it is determined
that blood oxygen
delivery is not impeded below a threshold value or does not fall within a
predetermined range of
values, the physician explores an alternate treatment option (which may
include no treatment or
the delipidation process of the present specification). In an embodiment, the
threshold value is
80%. In an embodiment, the range of values is 1%-79%.
At step 108c, a physician determines whether both the accumulated lipid-
containing
degenerative material, covering a lesion/plaque/area/region(s) is of an amount
or volume falling
within a predetermined range of percentages and blood oxygen delivery is
impeded as determined
by a predetermine range of percentages. If both conditions are met, in step
114a, the physician
treats those areas identified as ischemic areas (FFR measurement in a range of
1% to 79%, and
preferably below 80%) with a stent implant procedure and subsequently, the
remaining areas with
the delipidation process of the present specification. In step 114b, if both
threshold conditions are
not met, then the physician determines if either one of the conditions or
neither condition is met
and determines an appropriate course of treatment as outlined above.
In an example case, where the analysis from the imaging determines a FFR in
the range of
1% - 79%, and blockage due to lipids anywhere from 1 to 100%, a physician may
decide to
physically intervene to improve the blood flow as measured by FFR, and thus,
blood oxygen
delivery. In an embodiment, the physical intervention is performed by
surgically embedding a
stent in order to increase the rate of blood flow in the identified atheroma
area.
In another example, where the analysis from the imaging determines a FFR in
the range of
80% - 100%, and blockage due to lipids to be in the range of 20% - 70%, the
physician may opt
for treatment methods that remove or reduce the lipids. In this example,
embodiments of the
present specification that enable selective modification of HDL particles are
utilized.
In yet another example, where the FFR is determined to be in a range of 1% to
79%, and
preferably less than 80%, and blockage due to lipids is in the range of 20% -
70%, the physician
may opt to proceed with the surgical process of embedding a stent. It should
be appreciated that
when a percentage blockage is stated, such as 20%-70%, it means that a cross-
sectional area of a
vessel is blocked with lipid containing material and that such blockage
occupies a range of 20%
to 70% of the cross-sectional area of the vessel.
If arteries with lipid-containing atheroma lesion/plaque/area/region(s) having
an amount
or volume of lipid blockage within a predetermined range of percentages are
identified in step
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110a, the patient is then subjected to the delipidation process. In this case,
at step 120, a blood
fraction of the patient is obtained. The process of blood fractionation is
typically done by filtration,
centrifuging the blood, aspiration, or any other method known to persons
skilled in the art. Blood
fractionation separates the plasma from the blood. In one embodiment, blood is
withdrawn from
a patient in a volume sufficient to produce about 12m1/kg of plasma based on
body weight. The
blood is separated into plasma and red blood cells using methods commonly
known to one of skill
in the art, such as plasmapheresis. Then the red blood cells are stored in an
appropriate storage
solution or returned to the patient during plasmapheresis. The red blood cells
are preferably
returned to the patient during plasmapheresis. Physiological saline is also
optionally administered
to the patient to replenish volume.
Blood fractionation is known to persons of ordinary skill in the art, and is
performed
remotely from the method described in context of FIG. IA. During the
fractionation, the blood
can optionally be combined with an anticoagulant, such as sodium citrate, and
centrifuged at forces
approximately equal to 2,000 times gravity. The red blood cells are then
aspirated from the plasma.
Subsequent to fractionation, the cells are returned to the patient. In some
alternate embodiments,
Low Density Lipoprotein (LDL) is also separated from the plasma. Separated LDL
is usually
discarded. In alternative embodiments, LDL is retained in the plasma. In
accordance with
embodiments of the present specification, blood fraction obtained at 120
includes plasma with
High Density Lipoprotein (HDL), and may or may not include other protein
particles. In
embodiments, autologous plasma collected from the patient is subsequently
treated via an
approved plasmapheresis device. The plasma may be transported using a
continuous or batch
process.
At step 122, the blood fraction obtained at 120 is mixed with one or more
solvents, such as
lipid removing agents. In an embodiment, the solvents used include either or
both of organic
solvents sevoflurane and n-butanol. In embodiments, the plasma and solvent are
introduced into
at least one apparatus for mixing, agitating, or otherwise contacting the
plasma with the solvent.
In embodiments, the solvent system is optimally designed such that only the
HDL particles are
treated to reduce their lipid levels and LDL levels are not affected. The
solvent system includes
factoring in variables such as solvent employed, mixing method, time, and
temperature. Solvent
type, ratios and concentrations may vary in this step. Acceptable ratios of
solvent to plasma
include any combination of solvent and plasma. In some embodiments, ratios
used are 2 parts
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plasma to 1 part solvent, 1 part plasma to 1 part solvent, or 1 part plasma to
2 parts solvent. In an
embodiment, when using a solvent comprising 95 parts sevoflurane to 5 parts n-
butanol, a ratio of
two parts solvent per one part plasma is used. Additionally, in an embodiment
employing a solvent
containing n-butanol, the present specification uses a ratio of solvent to
plasma that yields at least
3% n-butanol in the final solvent/plasma mixture. In an embodiment, a final
concentration of n-
butanol in the final solvent/plasma mixture is 3.33%. The plasma and solvent
are introduced into
at least one apparatus for mixing, agitating, or otherwise contacting the
plasma with the solvent.
The plasma may be transported using a continuous or batch process. Further,
various sensing
means may be included to monitor pressures, temperatures, flow rates, solvent
levels, and the like.
The solvents dissolve lipids from the plasma. In embodiments of the present
specification, the
solvents dissolve lipids to yield treated plasma that contains modified HDL
particles with reduced
lipid content. The process is designed such that HDL particles are treated to
reduce their lipid
levels and yield modified HDL particles without destruction of plasma proteins
or substantially
affecting LDL particles.
Energy is introduced into the system in the form of varied mixing methods,
time, and speed.
At 124, bulk solvents are removed from the modified HDL particles via
centrifugation. In
embodiments, any remaining soluble solvent is removed via charcoal adsorption,
evaporation, or
Hollow Fiber Contractors (HFC) pervaporation. The mixture is optionally tested
for residual
solvent via use of chromatography (GC), or similar means. The test for
residual solvent may
optionally be eliminated based on statistical validation.
At 126, the treated plasma containing modified HDL particles with reduced
lipid content,
which was separated from the solvents at 124, is treated appropriately and
subsequently returned
to the patient. The modified HDL particles are HDL particles with an increased
concentration of
pre-beta HDL. Concentration of pre-beta HDL is greater in the modified HDL,
relative to the
original HDL that was present in the plasma before treating it with the
solvent. The resulting
treated plasma containing the HDL particles with reduced lipid and increased
pre-beta
concentration is optionally combined with the patient's red blood cells, if
the red cells were not
already returned during plasmapheresis, and administered to the patient. One
route of
administration is through the vascular system, preferably intravenously.
In embodiments, the patient is monitored again for changes in the previously
monitored
atheroma areas and volumes, specifically for lipid-containing degenerative
material. Therefore
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the process is repeated from step 102, as described above. In embodiments, the
patient is
monitored repeatedly within a period of three to six months. The treatment
cycle is also repeated
at this frequency until the monitoring suggests substantially or completely
enhanced cholesterol
efflux. In an embodiment, when the atheroma area and volume are monitored to
be below
threshold, the patient may be considered to have been treated and may not
require further repetition
of the treatment cycle. In some embodiments, frequency of treatment may vary
depending on the
volume to be treated and the severity of the condition of the patient.
Atheroembolic Renal Disease
Renal Arterial Stenosis (RAS) is a systemic disease and patients may have
multiple lesions
throughout their vasculature. Sometimes, the plaque within the arteries may
break away and
damage kidneys, resulting in Atheroembolic Renal Disease (AERD). Therefore, it
should be noted
herein that the treatment methods of the present specification are not
implemented based on an
overall patient health-based treatment strategy, but rather a
"lesion/plaque/area/region"-based
treatment strategy.
FIG. 1B is a flow chart illustrating another exemplary process of treating
cholesterol-
related diseases, such as, but not limited to Atheroembolic Renal Disease
(AERD), in accordance
with some embodiments of the present specification. In all cases, a patient
first presents with renal
arterial stenosis - a blockage in an artery that supplies blood to the kidney.
At step 132, it is
determined whether a patient has elevated Blood Pressure (BP). Recent onset of
hypertension may
be a clinical manifestation of the presence of plaque. If it is determined
that the patient has High
BP (HBP), the physician, may look for atheroembolic renal disease (AERD) at
step 134. While
AERD may not cause any symptoms, some of the following symptoms may appear
slowly and
worsen over time: blood in the urine, fever, muscle aches, headache, weight
loss, foot pain or blue
toes, nausea, among other symptoms. If AERD is not identified, then at 136, a
stent is placed in
the patient to reverse any blockage that may be resulting in HBP.
If, at 134, AERD is identified in addition to elevated BP, then the physician
may place a
stent at step 138 in order to reverse blockage and elevations in BP.
Additionally, at step 140, the
physician may determine whether the procedure of placing a stent has worked to
address both
elevated BP levels and AERD. If not, an additional stent may be placed, or the
delipidation process,
in accordance with embodiments of the present specification and described with
respect to FIG.
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1A, may be used. The treatment decision may be based on
"lesion/plaque/area/region"
determination.
At step 132, if it is determined that the patient has normal levels of BP, the
physician may
still check for symptoms or signs of AERD at step 142. The check may be
conducted on the basis
of symptoms such as, but not limited to, blindness, blood in the urine, fever,
muscle aches,
headache, weight loss, foot pain or blue toes, nausea, among other symptoms.
If, at 142, AERD
is not detected, then, at step 144, the physician may determine an appropriate
course of treatment,
based on the symptoms and any other diagnosis. If there is renal stenosis (the
presence of
cholesterol-containing plaque) absent both elevated HBP and AERD, then the
physician may opt
to follow the procedure outlined above in context of FIG. 1A for
cardiovascular diseases, which
can result in either one or both of a stent and/or the delipidation process of
the present specification.
If the patient is diagnosed with AERD but has normal BP levels, then the
physician may
proceed to step 146, and the subject or the patient is monitored for one or
more atheroma areas
and/or volumes via a diagnostic procedure to determine the cause of renal
dysfunction, and the
extent of renal arterial stenosis. In an embodiment, advanced medical imaging
techniques, such
as, but not limited to Computer Tomography (CT) angiogram and/or Intravascular
Ultrasound
(IVUS) and/or Near IR spectroscopy, may be used to detect areas within the
inner layer of artery
walls where lipid-containing degenerative material may have accumulated.
Accumulated
degenerative material may include fatty deposits which may include mostly
macrophage cells, or
.. debris, containing lipids, calcium and a variable amount of fibrous
connective tissue. Analysis
from the imaging techniques may also be used to identify and therefore monitor
volumes of lipid-
containing degenerative material accumulated within the inner layer of artery
walls. Lipid-
containing degenerative material and non-lipid-containing degenerative
material may swell in the
artery wall, thereby intruding into the channel of the artery and narrowing
it, resulting in restricting
of blood flow and causing renal abnormalities.
Based on analysis from the diagnostic technique, the presence and type of
degenerative
material is confirmed, the extent or percentage of degenerative material
(lipid-containing or non-
lipid-containing) is determined, and the extent of blood oxygen delivery based
on Fractional Flow
Reserve (FFR) is identified. The process is stopped if no degenerative
material is detected, or if
the level of degenerative material is below a predetermined threshold or falls
outside of a
predetermined range of values. In an embodiment, the physician identifies one
or more renal
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arteries with stenosis that have a blockage of 20% - 70% due to accumulated
lipids, in order to
implement treatment methods in accordance with the present specification. In
an embodiment,
FFR is used to measure pressure differences across arterial stenosis to
determine the likelihood
that the stenosis impedes blood flow, and thus, oxygen delivery to the kidney
(ischemia).
Different types of treatments may be provided depending on the diagnostic
results and
threshold values. At this stage, the physician may determine that either the
treatment in accordance
with embodiments of the present specification is not required as the disease
has subsided, is not
present, is not sufficient, or has been treated; or an alternative form of
treatment is required.
Referring back to FIG. 1C, the table compares different types of treatments
that may be
administered for combinations of various ranges of a Fractional Flow Reserve
(FFR) 402, which
is indicative of a change in rate of flow of blood associated with a blockage
(and thus blood oxygen
delivery), provided in terms of percentage of FFR, and various ranges of
blockage due to lipid
content 404, provided in terms of percentage of blockage due to lipid content.
Referring to the
table, each cell, such as cells 406, correspond to a combination of a range
402 (indicative of FFR)
and a range 404 (indicative of the percentage or extent of blockage due to
lipid content), which
further indicates at least one method of treatment that may be suitable for
that combination.
In embodiments, the different types of treatments are coded as A, B, C, and D.
Treatment
type 'A' corresponds to an invasive treatment process where a stent is
embedded through physical
intervention. Treatment type '13' corresponds to implementing the treatment
methods of
.. selectively modifying HDL particles, in accordance with the embodiments of
the present
specification. In an embodiment, it is preferable to selectively modify HDL
particles (and perform
the HDL infusions) where the Fractional Flow Reserve (FFR) ranges from 80-100%
and the
accumulated lipid obstruction ranges from 20-70%, as noted by sections 404. It
should be noted
herein that in embodiments, a FFR of 1-79% represents an ischemic condition,
wherein 80-100%
FFR represents a non-ischemic condition. Treatment type 'C' corresponds to
cases where a
combination of both a stent as well as selective modification of HDL particles
is administered. In
most cases, treatment types 'A' and/or '13' may be able to address the
condition. Treatment type
'D' corresponds to cases where neither of the stated treatment types (A, B, or
C) is required. In
some cells, such as cells 408, two treatment options may be indicated and the
physician would
decide upon the appropriate course of treatment.
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Renal Arterial Stenosis (RAS) is a systemic disease and patients may have
multiple lesions
throughout their vasculature. It should be noted herein that the treatment
methods of the present
specification are not implemented based on an overall patient health-based
treatment strategy, but
rather a "lesion/plaque/area/region"-based treatment strategy. Thus, in a few
cases, a physician
may decide to combine the treatments and administer treatment type 'C'. If, in
a particular patient,
one or more areas or lesions have a FFR percentage measured at 79% or less,
then those areas
would have a stent implanted. If the same patient presents with additional,
remaining lesions that
exhibit lipid-based blockage in the range of 20-70% and also an FFR of 80-
100%, then the patient
would undergo a subsequent delipidation. Therefore, both interventions may be
used for patients
having multiple lesions with different levels of disease at each lesion.
The physician determines whether the amount of accumulated lipid-containing
degenerative material, covering a lesion/plaque/area/region, falls above or
below a predetermined
threshold percentage or within a predetermined range of percentages, as
measured in terms of a
percentage of blockage due to lipid content. If arteries with lipid-containing
atheroma lesion(s)
having an amount or volume above or below a threshold percentage or falling
within a
predetermined range of percentages are not identified, an alternative
treatment process (which may
include no treatment or physical intervention) is determined by the physician.
If arteries with lipid-
containing atheroma lesion/plaque/area/region(s) having an amount or volume of
lipid blockage
falling within a predetermined range of percentages are identified, the
patient is then subjected to
the delipidation process. The delipidation process of the present
specification is described in
greater detail with respect to FIG. 1A.
The physician also determines whether, based on the FFR measurement, blood
oxygen
delivery is impeded below a threshold value or falls within a range of values
(which is expressed
as the maximal flow of blood down a vessel in the presence of stenosis
compared to the maximal
flow in the hypothetical absence of stenosis). If blood oxygen delivery is
impeded below a
threshold value or falls within a range of values, a physician treats with
physical intervention, such
as a stent. If it is determined that blood oxygen delivery is not impeded
above a threshold value,
the physician explores an alternate treatment option (which may include no
treatment or the
delipidation process of the present specification). In an embodiment, the
threshold value is 80%.
In an embodiment, the range of values is 1%-79%.
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Subsequently, a physician determines whether both the accumulated lipid-
containing
degenerative material, covering a lesion/plaque/area/region(s) is in an amount
or volume within a
predetermined range of percentages and blood oxygen delivery is impeded above
a threshold value
or within a predetermined range of values. If both threshold conditions are
met, the physician
treats those areas identified as ischemic areas (FFR below 80%, or within a
range of 1% t079%)
with a stent implant procedure and subsequently, the remaining areas with the
delipidation process
of the present specification. If both threshold conditions are not met, then
the physician determines
if either one of the conditions or neither condition is met and determines an
appropriate course of
treatment as outlined above.
In an example case, where the analysis from the imaging determines a FFR in
the range of
1% - 79%, and blockage due to lipids anywhere from 1 to 100%, a physician may
decide to
physically intervene to improve blood oxygen delivery, as measured by FFR. In
an embodiment,
the physical intervention is performed by surgically embedding a stent in
order to increase the rate
of blood flow in the identified atheroma area.
In another example, where the analysis from the imaging determines a FFR in
the range of
80% - 100%, and blockage due to lipids to be in the range of 20% - 70%, the
physician may opt
for treatment methods that remove or reduce the lipids. In this example,
embodiments of the
present specification that enable selective modification of HDL particles are
utilized.
In yet another example, where the FFR is determined to be less than 80% (in a
range of 1%
to 79%), and blockage due to lipids is in the range of 20% - 70%, the
physician may opt to proceed
with the surgical process of embedding a stent. It should be appreciated that
when a percentage
blockage is stated, such as 20%-70%, it means that a cross-sectional area of a
vessel is blocked
with lipid containing material and that such blockage occupies a range of 20%
to 70% of the cross-
sectional area of the vessel.
If arteries with lipid-containing atheroma area/volume within a predetermined
range of
percentages are identified, the patient is then subjected to the delipidation
process. In this case, a
blood fraction of the patient is obtained. The process of blood fractionation
is typically done by
filtration, centrifuging the blood, aspiration, or any other method known to
persons skilled in the
art. Blood fractionation separates the plasma from the blood. In one
embodiment, blood is
withdrawn from a patient in a volume sufficient to produce about 12m1/kg of
plasma based on
body weight. The blood is separated into plasma and red blood cells using
methods commonly
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known to one of skill in the art, such as plasmapheresis. Then the red blood
cells are stored in an
appropriate storage solution or returned to the patient during plasmapheresis.
The red blood cells
are preferably returned to the patient during plasmapheresis. Physiological
saline is also optionally
administered to the patient to replenish volume.
Blood fractionation is known to persons of ordinary skill in the art, and is
performed
remotely from the method described in context of FIG. 1A. During the
fractionation, the blood
can optionally be combined with an anticoagulant, such as sodium citrate, and
centrifuged at forces
approximately equal to 2,000 times gravity. The red blood cells are then
aspirated from the plasma.
Subsequent to fractionation, the cells are returned to the patient. In some
alternate embodiments,
Low Density Lipoprotein (LDL) is also separated from the plasma. Separated LDL
is usually
discarded. In alternative embodiments, LDL is retained in the plasma. In
accordance with
embodiments of the present specification, obtained blood fraction includes
plasma with High
Density Lipoprotein (HDL), and may or may not include other protein particles.
In embodiments,
autologous plasma collected from the patient is subsequently treated via an
approved
plasmapheresis device. The plasma may be transported using a continuous or
batch process.
The blood fraction obtained is mixed with one or more solvents, such as lipid
removing
agents. In an embodiment, the solvents used include either or both of organic
solvents sevoflurane
and n-butanol. In embodiments, the plasma and solvent are introduced into at
least one apparatus
for mixing, agitating, or otherwise contacting the plasma with the solvent. In
embodiments, the
solvent system is optimally designed such that only the HDL particles are
treated to reduce their
lipid levels and LDL levels are not affected. The solvent system includes
factoring in variables
such as solvent employed, mixing method, time, and temperature. Solvent type,
ratios and
concentrations may vary in this step. Acceptable ratios of solvent to plasma
include any
combination of solvent and plasma. In some embodiments, ratios used are 2
parts plasma to 1 part
solvent, 1 part plasma to 1 part solvent, or 1 part plasma to 2 parts solvent.
In an embodiment,
when using a solvent comprising 95 parts sevoflurane to 5 parts n-butanol, a
ratio of two parts
solvent per one part plasma is used. Additionally, in an embodiment employing
a solvent
containing n-butanol, the present specification uses a ratio of solvent to
plasma that yields at least
3% n-butanol in the final solvent/plasma mixture. In an embodiment, a final
concentration of n-
butanol in the final solvent/plasma mixture is 3.33%. The plasma and solvent
are introduced into
at least one apparatus for mixing, agitating, or otherwise contacting the
plasma with the solvent.
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The plasma may be transported using a continuous or batch process. Further,
various sensing
means may be included to monitor pressures, temperatures, flow rates, solvent
levels, and the like.
The solvents dissolve lipids from the plasma. In embodiments of the present
specification, the
solvents dissolve lipids to yield treated plasma that contains modified HDL
particles with reduced
lipid content. The process is designed such that HDL particles are treated to
reduce their lipid
levels and yield modified HDL particles without destruction of plasma proteins
or substantially
affecting LDL particles.
Energy is introduced into the system in the form of varied mixing methods,
time, and speed.
Bulk solvents are removed from the modified HDL particles via centrifugation.
In embodiments,
any remaining soluble solvent is removed via charcoal adsorption, evaporation,
or Hollow Fiber
Contractors (HFC) pervaporation. The mixture is optionally tested for residual
solvent via use of
chromatography (GC), or similar means. The test for residual solvent may
optionally be
eliminated based on statistical validation.
The treated plasma containing modified HDL particles with reduced lipid
content, which
was separated from the solvents, is treated appropriately and subsequently
returned to the patient.
The modified HDL particles are HDL particles with an increased concentration
of pre-beta HDL.
Concentration of pre-beta HDL is greater in the modified HDL, relative to the
original HDL that
was present in the plasma before treating it with the solvent. The resulting
treated plasma
containing the HDL particles with reduced lipid and increased pre-beta
concentration is optionally
combined with the patient's red blood cells, if the red cells were not already
returned during
plasmapheresis, and administered to the patient. One route of administration
is through the
vascular system, preferably intravenously.
In embodiments, the patient is monitored again for changes in the previously
monitored
atheroma areas and volumes, specifically for lipid-containing degenerative
material. Therefore
the process is repeated, as described above. In embodiments, the patient is
monitored repeatedly
within a period of three to six months. The treatment cycle is also repeated
at this frequency until
the monitoring suggests substantially or completely enhanced cholesterol
efflux. In an
embodiment, when the atheroma area and volume are monitored to be below
threshold, the patient
may be considered to have been treated and may not require further repetition
of the treatment
cycle. In some embodiments, frequency of treatment may vary depending on the
volume to be
treated and the severity of the condition of the patient.
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Alzheimer's disease
Alzheimer's disease is determined using results from several tests to arrive
at a differential
diagnosis. Thus, there is no definitive diagnosis for Alzheimer's disease. In
embodiments,
treatments and protocols of the present specification are applicable to
patients exhibiting pre-
symptomatology of AD, in addition to symptoms related to altered global
function, cognitive
function, activities of daily living (ADL)/functional impairment, and
behavior. Thus, patients
suffering from AD can be characterized as having early stage (pre-
symptomatic)/Stages 1-4, mild,
moderate, or severe AD based upon the totality of symptoms.
The following categories may be assigned and are provided for the design and
evaluation
of benefits throughout the different early stages of AD:
= Stage 1 is representative of a class of patients with characteristic
pathophysiologic changes of
early onset AD but no evidence of clinical impact. These patients are truly
asymptomatic with
no subjective complaint, functional impairment, or detectable abnormalities on
sensitive
neuropsychological measures. The characteristic pathophysiologic changes are
typically
demonstrated by assessment of various biomarker measures.
= Stage 2 includes the group of patients with characteristic
pathophysiologic changes of early
onset AD and subtle detectable abnormalities on sensitive neuropsychological
measures, but
no functional impairment. The emergence of subtle functional impairment
signals a transition
to Stage 3.
= Stage 3 is representative of a class of patients with characteristic
pathophysiologic changes of
early onset AD, subtle or more apparent detectable abnormalities on sensitive
neuropsychological measures, and mild but detectable functional impairment.
The functional
impairment in this stage is not severe enough to warrant a diagnosis of overt
dementia.
= Stage 4 includes a group of patients with overt dementia. This diagnosis is
made as functional
impairment worsens from that seen in Stage 3. This stage may be refined into
additional
categories which correspond to mild, moderate, and severe Alzheimer's disease
states as
described below.
= Stages 5, 6, and 7 correspond to increasing degrees of overt dementia
and/or functional
impairment. As such, stages 5, 6, and 7 correspond to mild, moderate, and
severe AD.
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In embodiments, a baseline, starting or initial severity level is
diagnosed/assessed using at
least one physiological diagnostic or advanced medical imaging technique. In
some embodiments,
a baseline, starting or initial severity level is additionally assessed by at
least one cognitive
measurement or test. Given the panoply of available neuropsychological tests,
a pattern of
putatively beneficial effects demonstrated across multiple individual tests
may be used to assess
impact in early AD or a large magnitude of effect on a single sensitive
measure of
neuropsychological performance may be used. For example, measuring the level
of amyloid
peptide (including 40 and 42) may be used to assess a possible treatment
benefit.
Differential diagnosis and the assessment of the severity level of Alzheimer's
disease may
be based on one or more global, cognitive, functional and behavioral
measurements, assessments,
or tests.
In embodiments, global assessment tests may include assessments such as, but
not limited
to Clinician's Interview-Based Impression of Change plus caregiver assessment
(the CIBIC-plus),
and Clinical Dementia Rating-sum of boxes (CDR-SB).
Clinician's Interview-Based Impression of Change plus caregiver input (the
CIBIC-plus)
is not a single or standardized instrument, such as the ADAS-cog described
below. Clinical trials
for investigational drugs have used a variety of CIBIC formats, each different
in terms of depth
and structure. As such, results from a CIBIC-plus reflect clinical experiences
from the trial or trials
in which it was used and cannot be compared directly with the results of CIBIC-
plus evaluations
from other clinical trials. By way of example, the CIBIC-plus used in some
major trials is a semi-
structured instrument that was intended to examine four major areas of patient
function: General,
Cognitive, Behavioral, and Activities of Daily Living. It represents the
assessment of a skilled
clinician based upon his/her observations at an interview with the patient, in
combination with
information supplied by a caregiver familiar with the behavior of the patient
over the interval rated.
The CIBIC- plus is scored as a seven-point categorical rating, ranging from a
score of 1, indicating
"markedly improved," to a score of 4, indicating "no change" to a score of 7,
indicating "markedly
worse." The CIBIC-plus has not been systematically compared directly to
assessments not using
information from caregivers (CIBIC) or other global methods.
Clinical Dementia Rating-sum of boxes (CDR-SB) measures cognitive performance
in six
areas: memory, orientation, judgment/problem solving, community affairs,
home/hobbies,
personal care. Each category is scored on five-point scale of impairment
(0=none,
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0.5=questionable, 1=mild, 2=moderate, 3=severe). The sum of ratings (0-18)
provides the overall
CDR-SB assessment.
In embodiments, cognitive tests may include assessments such as, but not
limited to, the
cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog) and
Mini Mental
State Examination (MNISE).
The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog)
is a
multi-factor instrument that has been extensively validated in longitudinal
cohorts of Alzheimer's
disease patients. The ADAS-cog examines selected aspects of cognitive
performance including
elements of memory, orientation, attention, reasoning, language, and praxis.
The ADAS-cog
scoring range is from 0 to 70, with higher scores indicating greater cognitive
impairment. Elderly
adults with normal cognitive functionality may score as low as 0 or 1, but it
is not unusual for
adults not presenting with typical dementia to score slightly higher.
The Mini Mental State Examination (MMSE) includes 11 questions regarding
orientation,
memory, concentration, language, and praxis. The scoring scale ranges from 0
to 30, with a higher
score indicating lower impairment.
In embodiments, functional tests or tests that assess impairment in activities
of daily living,
may include assessments such as, but not limited to, Severe Impairment Battery
(SIB), Modified
Alzheimer's disease Cooperative Study-activities of daily living inventory
(ADCS-ADL) and
Modified Alzheimer's disease Cooperative Study-activities of daily living
inventory for severe
Alzheimer's disease (ADCS-ADL-severe), Progressive Deterioration Scale (PDS),
Instrumental
Activities of Daily Living (IADL), and the Katz Activities of Daily Living
(ADL) index.
The Severe Impairment Battery (SIB) assessment is a multi-item instrument and
has been
validated for the evaluation of cognitive function in patients presenting with
moderate to severe
dementia. The SIB evaluates selective aspects of cognitive performance,
including elements of
memory, language, orientation, attention, praxis, visuospatial ability,
construction, and social
interaction. The SIB scoring range is from 0 to 100, with lower scores
indicating greater cognitive
impairment.
The Modified Alzheimer's Disease Cooperative Study-Activities of Daily Living
inventory (ADCS-ADL) consists of a comprehensive battery of ADL questions used
to measure
the functional capabilities of patients. Each ADL item is rated from the
highest level of
independent performance to complete loss. The investigator performs the
inventory by
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interviewing a caregiver familiar with the behavior of the patient. A subset
of 19 items, including
ratings of the patient's ability to eat, dress, bathe, telephone, travel,
shop, and perform other
household chores has been validated for the assessment of patients with
moderate to severe
dementia. The modified ADCS-ADL has a scoring range of 0 to 54, with the lower
scores
indicative of greater functional impairment.
The Modified Alzheimer's Disease Cooperative Study - Activities of Daily
Living
Inventory for Severe Alzheimer's Disease (ADCS-ADL-severe) is derived from the
Alzheimer's
Disease Cooperative Study-Activities of Daily Living Inventory described
above, which is a
comprehensive battery of ADL questions used to measure the functional
capabilities of patients.
Each ADL item is rated from the highest level of independent performance to
complete loss. The
ADCS-ADL-severe is a subset of 19 items, including ratings of the patient's
ability to eat, dress,
bathe, use the telephone, get around (or travel), and perform other activities
of daily living; it has
been validated for the assessment of patients with moderate to severe
dementia. The ADCS-ADL-
severe has a scoring range of 0 to 54, with the lower scores indicative of
greater functional
impairment. The investigator performs the inventory by interviewing a
caregiver, such as a nurse
staff member, who is familiar with the overall functional capability of the
patient.
The Progressive Deterioration Scale (PDS) examines activities of daily living
(ADL) and
instrumental ADL in 11 areas, including the extent to which the patient can
leave the immediate
neighborhood, the use of familiar household implements, involvement in family
finances and
budgeting, self-care, and routine tasks. The scoring scale ranges from 0 to
100, wherein a higher
score indicating better overall functional capability.
The Instrumental Activities of Daily Living (IADL) assessment is used to
measure
competence in complex ADL, including telephoning, shopping, food preparation,
housekeeping,
laundering, use of transportation, use of medicine, and the ability to handle
money. Each
behavioral area is scored 1 or 0. A higher composite score indicates better
functional performance.
The Katz Activities of Daily Living (ADL) index is used to assess a patient's
ability to
perform ADL independently in six functions of bathing, dressing, toileting,
transferring,
continence, and feeding. Each function is assigned a score of yes or no for
independence in that
function, whereby each "yes" answer generates one point. A total score of 6
indicates full
functional capability while a score of 2 or less is indicative of severe
functional impairment.
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In embodiments, behavioral and mood tests may include assessments such as, but
not
limited to, Neuropsychiatric Inventory (NPI) and are employed to determine an
extent of
depression, anxiety, irritability, and overall mood shifts.
The Neuropsychiatric Inventory (NPI) evaluates 10 items including delusions,
hallucinations, dysphoria, anxiety, agitation, euphoria, apathy, irritability,
disinhibition, aberrant
motor behavior (pacing and rummaging). Two more items may also be assessed,
specifically,
night-time behavior and changes in appetite and eating behaviors. The
frequency of behavioral
disturbances are rated on a four-point scale with the severity rated on three-
point scale. A higher
total score is indicative of more behavioral problems.
In some cases, diagnostic imaging tests are used to determine the accumulation
or regional
lesions of plaque in the perivascular space. The advanced medical imaging
techniques are used to
both determine the extent of plaque in the perivascular space and to assess a
severity level of
Alzheimer's disease. In embodiments, advanced medical imaging techniques, such
as, but not
limited to, Positron Emission Tomography (PET), Magnetic Resonance Imaging
(MRI) and Spinal
Fluid Test (Beta Amyloid Fragments), may be used.
A specific Amyloid Positron Emission Tomography (PET) Scan, also referred to
as
Amyloid PET imaging, represents a potential major advance in an early
diagnosis of Alzheimer's
disease and/or an assessment of the degree of cognitive impairment. The scan
visualizes plaque
regions or lesions present in the brain, which are prime suspects in damaging
and killing nerve
cells in Alzheimer's patients. The scan technique employs radioactive tracers
to highlight amyloid
protein plaque regions or lesions within the brain, which are a hallmark of
Alzheimer's disease.
Amyloid PET scanning enables the "illumination" of amyloid plaques on a brain
PET scan,
enabling accurate detection of plaques in living people. The scan may allow
for an earlier diagnosis
or assessment of Alzheimer's disease, prior to the presentation of
symptomatology.
The practice parameters for the diagnosis and evaluation of dementia, as
published by the
American Academy of Neurology (AAN), consider structural brain imaging
optimal, wherein MRI
is one of the appropriate imaging methods. The AAN suggests that neuroimaging
may be most
useful in patients with dementia characterized by an early onset or an unusual
course. Thus,
Magnetic Resonance Imaging (MRI) may be considered a preferred neuroimaging
examination
for diagnosis and assessment of Alzheimer's disease because it allows for
accurate measurement
of the 3-dimensional (3D) volume of brain structures, and in particular, the
size of the hippocampus
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and related regions. Neuroimaging is widely believed to be generally useful
for excluding
reversible causes of dementia syndrome, such as normal-pressure hydrocephalus,
brain tumors,
and subdural hematoma, and for excluding other likely causes of dementia, such
as cerebrovascular
disease, thereby enabling a differential diagnosis of AD.
Spinal Fluid Test (detection of Beta Amyloid Fragments), is a diagnostic test
that requires
drawing fluid from the spinal region. Researchers have identified a protein
"signature" in the
spinal fluid of patients with Alzheimer's disease, which could represent an
important advance in
its diagnosis. The signature was found in the cerebrospinal fluid (CSF) of 90%
of people with a
diagnosis of Alzheimer's disease and 72% of people with mild cognitive
impairment (MCI) - a
disorder that often progresses to Alzheimer's. Researchers measured
concentrations of three
proteins previously identified as potential biological indicators, or
biomarkers, for Alzheimer's and
MCI: amyloid-beta, tau, and phospho-tau. Alzheimer's disease was identified in
three independent
study groups wherein the participants exhibited low levels of the amyloid
protein amyloid-beta 1-
42, along with high levels of total tau and elevated phospho-tau 181 (P-tau
181).
Apolipoprotein E (ApoE) is a class of proteins involved in the metabolism of
fats in the
body and is the principal cholesterol carrier in the brain. ApoE is
polymorphic, with three major
alleles, namely ApoE-c2, ApoE-c3, and ApoE-c4. ApoE-e2 has an allele frequency
of
approximately 7% to 8% in the general population. This variant of the
apolipoprotein binds poorly
to cell surface receptors while ApoE-e3 and ApoE-e4 bind relatively well. ApoE-
e2 is associated
with both increased and decreased risk for atherosclerosis. Individuals with a
c2k2 combination
tend to clear dietary fat more slowly and be at greater risk for early
vascular disease and the genetic
disorder type III hyperlipoproteinemia. ApoE-e3 has an allele frequency of
approximately 80% in
the general population. It is considered the "neutral" ApoE genotype of the
three. ApoE-e4 has an
allele frequency of approximately 14% in the general population. The e4
variant is the largest
known genetic risk factor for late-onset sporadic Alzheimer's disease (AD).
Although 40-65% of AD patients have at least one copy of the e4 allele, ApoE-
e4 is not a
definitive determinant of the disease; at least one-third of patients with AD
are ApoE-e4 negative
and some people with ApoE-e4 homozygotes never develop the disease. Yet,
studies show that
those with two e4 alleles have up to 20 times the risk of developing AD and
thus, it can be
implicated as at least a contributing factor. There is also evidence that the
ApoE-e2 allele may
serve a protective role in AD. Thus, the genotype most at risk for Alzheimer's
disease and at an
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earlier age is ApoE-E4, ApoE-E4. Using genotype ApoE-E3, ApoE-E3 as a
benchmark (allocating
a risk factor of 1.0 to the persons who have this genotype), individuals with
genotype ApoE-E4,
ApoE-E4 have a relative risk factor of 14.9 of developing Alzheimer's disease.
Individuals with the
ApoE-E3, ApoE-E4 genotype exhibit a relative risk factor of 3.2, while people
with the E2 allele
and the E4 allele (ApoE-E2, ApoE-E4) have a relative risk factor of 2.6.
Persons with one copy
each of the E2 allele and the E3 allele (ApoE-E2, ApoE-E3) have a relative
risk factor of 0.6, as do
persons with two copies of the 2 allele (ApoE-E2, ApoE-E2).
While ApoE-E4 has been found to greatly increase the likelihood that an
individual will
develop Alzheimer's disease, it should be noted that persons with any
combination of independent
risk factors, such as but not limited to different levels of certain ApoE
alleles as described above,
high overall serum total cholesterol levels, and high blood pressure have an
amplified risk of
developing AD at some point in their lifetime. Accordingly, research has
suggested that lowering
serum cholesterol levels may reduce a person's risk for Alzheimer's disease,
even if they have two
ApoE-E4 alleles, thus reducing the risk from nine or ten times the odds of
developing AD down to
just two times the odds. Women are more likely to develop AD than men across
most ages and
persons with at least one E4 allele have significantly more neurological
dysfunction than men.
In aspects of the present specification, a treated plasma that contains
modified HDL
particles with reduced lipid content is delivered to the patient via infusion
therapy. The process is
designed such that HDL particles are treated to reduce their lipid levels and
yield modified HDL
particles without destruction of plasma proteins or substantially affecting
LDL particles.
The HDL lipoprotein particles are comprised of ApoA-I, phospholipids and
cholesterol.
Persons of ordinary skill in the art would appreciate that Apolipoprotein A-I
(ApoA-I) particles
comprise of two sub-fractions, pre-f3 HDL and a-HDL, which have pre-beta and
alpha
electrophoretic mobility, respectively. Thus, pre-f3 HDL 645 represents ApoA-I
molecules
complexed with phospholipids.
In aspects of the present specification, a treated plasma that contains
modified HDL
particles with reduced lipid content is delivered to the patient via infusion
therapy. In an
embodiment, the modified high density lipoproteins have a concentration of
alpha high density
lipoproteins in addition to the pre-beta high density lipoproteins from the
blood fraction prior to
mixing.
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In aspects of the present specification, isolated pre-f3 HDL particles are
infused into the
patient's blood stream to bind to beta amyloid particles and clear the
cerebral perivascular pathway.
FIG. 4 is a longitudinal transverse cross-sectional view 405 of a cerebral
blood vessel 410
illustrating removal of beta amyloid by transport along the cerebral lymphatic
perivascular
pathway, in accordance with an embodiment of the present specification. As
shown, blood
circulates through the lumen 415 of the vessel 410 while Interstitial Fluid
(ISF) and solutes,
including beta amyloid (A13) 420, are eliminated from the brain through the
perivascular drainage
pathway 425, which is, effective, the lymphatic drainage of the brain. The e3
allele 430 binds to
beta amyloid particles 420, forming modified e3 particles, and thereby
transporting beta amyloid
particles 420 from the brain along the perivascular drainage pathway 425. Also
shown are
Apolipoprotein A-I (ApoA-I) particles 435 and HDL particles 440 as part of the
blood circulation
455 through the lumen 415 along with other particles such as, for example, red
blood cells 450.
AD is, in some cases, characterized by build-ups of aggregates of the peptide
beta-amyloid in the
cerebral lymphatic perivascular pathways. As illustrated in Table A, in AD
patients the distribution
of c2, e3 and e4 alleles is approximately 4%, 60% and 37%, respectively. The
isoform ApoE-e4 is
not as effective as the alleles at promoting clearance of beta amyloid from
the cerebral perivascular
drainage pathways. Thus, a skewed abundance of e4 allele is associated with
increased
vulnerability to AD in individuals with that gene variation and in AD patients
is also associated
with an increase in the severity of AD and loss of cognitive function.
FIG. 5 is a longitudinal transverse cross-sectional view 505 of a cerebral
blood vessel 510
illustrating amyloid accumulation in cerebral lymphatic perivascular pathways
of individuals with
an increased presence of the e4 allele, in accordance with an embodiment of
the present
specification. As shown, blood circulates through the lumen 515 of the vessel
510 while beta
amyloid (A13) particles 520 are accumulated in the cerebral perivascular
pathway 525 due to an
increased presence of e4 particles 530. Thus, beta amyloid 520 is deposited in
the walls of the
blood vessel 510 as cerebral amyloid angiopathy (CAA). CAA in AD reflects a
failure of
elimination of amyloid-beta (A13) from the brain along perivascular lymphatic
drainage pathways
525. Failure of elimination of beta amyloid along perivascular pathways may
coincide with a
reduction in enzymatic degradation of beta amyloid, reduced absorption of beta
amyloid into the
blood and stiffening of blood vessel walls. Also shown are ApoA-I particles
535 and HDL
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particles 540 as part of the blood circulation 555 through the lumen 515 along
with other particles
such as, for example, red blood cells 550.
FIG. 6A is a longitudinal transverse cross-sectional view 605 of a cerebral
blood vessel
610 of an AD patient being treated for cerebral amyloid angiopathy (CAA), in
accordance with an
embodiment of the present specification. As shown, blood circulates through
the lumen 615 of the
vessel 610 while beta amyloid (A13) particles 620 accumulate in the cerebral
perivascular pathway
625 along with a high presence of e4 particles 630, thereby essentially
blocking pathway 625. In
accordance with an aspect of the present specification, treated plasma or
isolated pre-f3 HDL
particles 645 are infused into the patient's blood stream 655 to bind to beta
amyloid particles 620
and clear the cerebral perivascular pathway 625. Pre-f3 HDL 645 represents
ApoA-I molecules
complexed with phospholipids.
To generate and subsequently infuse the patient with treated plasma or with a
solution
containing an increased concentration of isolated pre-f3 HDL 645, a blood
fraction is obtained. The
process of blood fractionation is typically done by filtration, centrifuging
the blood, aspiration, or
any other method known to persons skilled in the art. Blood fractionation
separates the plasma
from the blood. In one embodiment, blood is withdrawn from a patient in a
volume sufficient to
produce about 12m1/kg of plasma based on body weight. The blood is separated
into plasma and
red blood cells using methods commonly known to one of skill in the art, such
as plasmapheresis.
Then the red blood cells are stored in an appropriate storage solution or
returned to the patient
during plasmapheresis. The red blood cells are preferably returned to the
patient during
plasmapheresis. Physiological saline is also optionally administered to the
patient to replenish
volume.
In some alternate embodiments, Low Density Lipoprotein (LDL) is also separated
from the
plasma. Separated LDL is usually discarded. In alternative embodiments, LDL is
retained in the
plasma. In accordance with embodiments of the present specification, the
resultant blood fraction
includes plasma with HDL, and may or may not include other protein particles.
In one embodiment, the process of blood fractionation is performed by
withdrawing blood
from the patient presenting with AD, and who is being treated by the
physician. In an alternative
embodiment, the process of blood fractionation is performed by withdrawing
blood from a person
other than the patient. Therefore, the plasma obtained as a result of the
blood fractionation process
may be either autologous or non-autologous.
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In an optional embodiment, the autologous or non-autologous plasma obtained is
subjected
to a delipidation process as described in greater detail above with respect to
FIG. lA but repeated
briefly herein. The resultant blood fraction is mixed with one or more
solvents, such as lipid
removing agents. In an embodiment, the solvents used include either or both of
organic solvents
sevoflurane and n-butanol. In embodiments, the plasma and solvent are
introduced into at least
one apparatus for mixing, agitating, or otherwise contacting the plasma with
the solvent. In
embodiments, the solvent system is optimally designed such that only the HDL
particles are treated
to reduce their lipid levels and LDL levels are not affected. The solvent
system includes factoring
in variables such as solvent employed, mixing method, time, and temperature.
Solvent type, ratios
and concentrations may vary in this step. The plasma and solvent are
introduced into at least one
apparatus for mixing, agitating, or otherwise contacting the plasma with the
solvent. The plasma
may be transported using a continuous or batch process. The solvents dissolve
lipids from the
plasma. In embodiments of the present specification, the solvents dissolve
lipids to yield treated
plasma that contains modified HDL particles with reduced lipid content. The
process is designed
such that HDL particles are treated to reduce their lipid levels and yield
modified HDL particles
without destruction of plasma proteins or substantially affecting LDL
particles. The resultant
treated plasma containing modified HDL particles with reduced lipid content,
which was separated
from the solvents, is treated appropriately and may subsequently returned to
the patient in an
embodiment.
In an optional embodiment, the resultant fluid containing modified HDL
particles is further
processed, in a second stage, to separate or to isolate pre-f3 HDL particles.
In an embodiment, the
second stage occurs in a separate and discrete area from the delipidation
process. In an alternate
embodiment, the second stage processing occurs in-line with the delipidation
system, whereby the
system may be connected to an affinity column sub-system or
ultracentrifugation sub-system. The
resultant separated pre-f3 HDL particles may then be introduced to the
bloodstream of the patient
as described below.
FIG. 6A illustrates a presence of non-modified HDL particles 640 in the blood
stream 655
along with other particles such as, for example, red blood cells 650. The
modified HDL particles
may be HDL particles with an increased concentration of pre-f3 HDL particles
645. Concentration
of pre-f3 HDL 645 is greater in the modified HDL, relative to the original HDL
that was present in
the plasma before treating it with the solvent. The resulting treated plasma
containing the HDL
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particles with reduced lipid and increased pre-f3 concentration is optionally
combined with the
patient's red blood cells, if the red cells were not already returned during
plasmapheresis, and
administered to the patient. One route of administration is through the
vascular system, preferably
intravenously, such as via infusion therapy.
FIG. 6B illustrates a mechanism of removal of beta amyloid molecules 620 by
infused pre-
p HDL particles 645 within the blood vessel 610 of an AD patient, in
accordance with an
embodiment of the present specification. As shown, with increased
concentration of pre-f3 HDL
particles 645 in the patient's blood stream 655, a relatively higher number of
pre-f3 HDL particles
645 are available to bind to and pull out beta-amyloid particles 620 from the
perivascular pathway
625. The pre-f3 HDL particles 645 in the blood stream 655 enter the
perivascular pathway 1025
and bind with beta-amyloid particles 620 to form modified pre-f3 HDL particles
645' that re-enter
the blood stream 655.
FIG. 6C shows a plurality of modified pre-f3 HDL particles 645' flowing in the
blood
stream 655 (in the lumen 615 of the blood vessel 610) and serving to transport
the bound beta
amyloid 620 to the liver for degradation and subsequent excretion. In some
embodiments, the pre-
p HDL particles 6145 also pull the e4 particles 630 along with the beta
amyloid molecules 620
from the perivascular pathway 625. In such embodiments, the modified pre-f3
HDL particles 645'
are pre-f3 HDL 645 binding both beta amyloid 620 and e4 630. Thus, the infused
isolated pre-f3
HDL particles 1145 initiate reverse cholesterol, specifically beta amyloid
620, transport process
from the cerebral perivascular pathways 625 to liver. Also seen in FIG. 6C are
non-modified HDL
particles 640 in the blood stream 655 along with other particles such as, for
example, red blood
cells 650.
Therapeutic protocols for administering modified HDL particles
In accordance with aspects of the present specification, treated plasma
containing modified
HDL particles with reduced lipid and/or increased pre-f3 concentration is
administered to a patient
in accordance with a plurality of therapeutic protocols. In some embodiments,
therapy is based on
a level of severity of AD, as described above. In various embodiments, the
plurality of therapy
protocols comprises at least one or any combination of a plurality of
therapeutic parameters such
as, but not limited to:
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= Dosing range: 1 mg/kg to 250 mg/kg, and any increment therein, where a
specific fixed dose
may be calculated based on one or both of a patient's weight and the severity
of the disease
state.
= Dosing volume: the average dosing volume is dependent upon the dose (in
mg/kg) and the
concentration of the product to be infused into the patient (treated plasma
containing modified
HDL particles or isolated pre-beta particles). In embodiments, the volume that
is returned to
the patient is substantially equal to the volume that was removed from the
patient prior to the
delipidation process. In embodiments, the volume that is returned to the
patient is a
concentrated volume. In embodiments, the volume delivered to a patient via
infusion therapy
is dependent upon the preparation of the product, whether it is treated plasma
or concentrated,
isolated pre-beta and the overall solubility of that product in a buffer or
saline.
= Dosing rate: the dose is provided via infusion therapy. It should be
noted herein that the rate
of infusion is the normal infusion rate for intravenous therapy, or 999
mL/hour and is thus
dependent on overall volume and concentration. In an embodiment, the time of
infusion ranges
from one hour to eight hours.
= Frequency or cycle of treatment: daily, weekly, monthly and annually
= Duration or course of therapy: at least one day to at least one year
FIG. 7 is a flowchart describing a plurality of exemplary steps of a therapy
protocol for
treating an AD patient, in accordance with an embodiment of the present
specification. At step
705, a patient first presents with a pathophysiological change that is
consistent with early onset
AD. Any of the aforementioned diagnostic techniques may be used in this step.
In embodiments
various biomarkers may be used to determine the pathophysiological change. For
example,
measuring the level of amyloid peptide (including 40 and 42) may be used to
assess the extent of
a pathophysiological change characteristic of AD. In an embodiment, the
patient may present with
cerebral amyloid angiopathy (CAA) as detected using a diagnostic imaging
technique. At step 710,
a patient who is diagnosed with CAA is monitored to determine an extent of
accumulation of
plaque in the perivascular space, via at least one diagnostic procedure. In
embodiments, advanced
medical imaging techniques, such as, but not limited to, Positron Emission
Tomography (PET),
Magnetic Resonance Imaging (Mill) and Spinal Fluid Test (Beta Amyloid
Fragments), may be
used.
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In embodiments, at optional step 715, the diagnosis and severity level of AD
in the patient
are additionally assessed based on one or more global, cognitive, functional,
and behavioral
measurements or tests, as described above.
In embodiments, global assessment tests may include assessments such as, but
not limited
to Clinician's Interview-Based Impression of Change plus caregiver assessment
(the CIBIC-plus),
and Clinical Dementia Rating-sum of boxes (CDR-SB).
In embodiments, cognitive tests may include assessments such as, but not
limited to,
cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog), and
Mini Mental
State Examination (MMSE).
In embodiments, functional tests may include assessments such as, but not
limited to,
severe impairment battery (SIB), modified Alzheimer's disease cooperative
study -activities of
daily living inventory (ADCS-ADL) and modified Alzheimer's disease cooperative
study
activities of daily living inventory for severe Alzheimer's disease (ADCS-ADL-
severe),
Progressive Deterioration Scale (PDS), Instrumental Activities of Daily Living
(IADL), and Katz
activities of daily living (ADL) index.
In embodiments, behavioral and mood tests may include assessments such as, but
not
limited to, Neuropsychiatric Inventory (NPI).
At step 720, one or more physiological parameters of the patient are recorded.
In
embodiments, the one or more physiological parameters are those that may be
incidental to
determining one or more therapy parameters. For example, the patient's weight
is recorded to
determine a dosing range for the patient. It should be appreciated that the
physiological parameters
may be first recorded prior to step 705.
At step 725, the patient is infused with modified HDL particles in accordance
with a
therapy protocol. In an optional embodiment, a blood fraction is withdrawn
from the patient
presenting with the CAA. In an alternative embodiment, a blood fraction is
obtained withdrawing
blood from a person other than the patient. Therefore, the plasma obtained as
a result of the blood
fractionation process may be either autologous or non-autologous. The blood
fraction is
subsequently treated, using the delipidation process described above to obtain
treated plasma
containing modified HDL particles. The treated plasma is optionally processed
further to generate
a product with an increased concentration of isolated pre-f3 HDL.
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In an embodiment, the therapy protocol comprises an infusion delivery of
modified HDL
particles or a concentrated volume of isolated pre-beta particles over a
period ranging from 1 hour
to 8 hours, and any increment therein, depending upon the concentration of the
therapeutic product
to be delivered. In some embodiments, the dose ranges from 1 mg/kg to 250
mg/kg, and any
increment therein, and is administered at an infusion delivery rate of 999
mL/hour +/- 100m1/hour
or a rate deemed more appropriate for the patient. In embodiments, the
treatment is repeated at
specified frequency or cycle of treatment depending upon a course of therapy.
In some
embodiments, the frequency or cycle of administering the treatment may range
from once a week,
twice a week, three times per week, daily, once a month, twice a month, three
times per month, to
at least once in three, six, nine or twelve months. In some embodiments, the
course of therapy may
range from at least one day, at least one week, at least one month to at least
one year.
In an alternate embodiment, the therapy protocol comprises at least one, and
up to three,
seven or ten treatments every three, six, nine or twelve months for an annual
course of therapy. In
some embodiments, the at least one treatment may comprise a continuous
infusion (IV) of
modified HDL particles over a predetermined time period at a rate of 999
mL/hour.
At optional step 730, the therapy protocol may be titrated or modulated up or
down based
on a therapeutic endpoint. In embodiments, one or more intra-treatment
severity level assessments
are made using diagnostic and/or cognitive procedures/tests. The one or more
intra-treatment
severity level assessments are made at predetermined points in time during the
course of therapy.
If the intra-treatment severity level assessments show a delay in the onset of
additional symptoms,
a halting in the worsening of symptoms, or an improvement in the patient's
condition, it is
considered to be of therapeutic benefit. In embodiments, when therapeutic
benefit is shown, the
therapeutic amount may be titrated down wherein parameters such as, but not
limited to, the dose
range, frequency or cycle of treatment and/or course of therapy may be
reduced. Alternately, the
therapy protocol may be titrated up depending on various factors. Still
alternately, if the intra-
treatment severity level assessments show or do not show improvement in the
patient's condition,
the therapy protocol is not modulated.
By way of example, for an early onset AD patient weighing 100kg, where a
dosage is
determined to be 15 mg/kg, that patient will receive a dose of 1.5g. It should
be noted that if the
patient presents with mild, moderate or severe AD, that dosage may be
increased. The overall
volume delivered to the patient via infusion therapy depends on the
therapeutic product that is
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solubilized in a buffer or saline. For example, if the therapeutic product is
autologous treated
plasma, then the patient will receive a volume of therapeutic product
equivalent to the volume that
was extracted from the patient. If the therapeutic product is non-autologous
treated plasma, the
patient may receive a volume of 1L as one example. If the therapeutic product
is non-autologous
isolated, concentrated pre-beta particles, the volume may be much lower.
Therapeutic endpoints or objectives
In various embodiments, an AD patient's baseline, starting or initial severity
level is
diagnosed/assessed and categorized as, one of early onset, mild, moderate or
severe as described
above. The baseline, starting or initial severity level refers to the severity
of AD before the patient
is treated with the modified HDL and/or isolated pre-f3 HDL therapy of the
present specification.
In embodiments, the baseline, starting or initial severity level is
diagnosed/assessed using
at least one physiological diagnostic or advanced medical imaging technique.
In some
embodiments, the baseline, starting or initial severity level is additionally
assessed by at least one
global, cognitive, functional, behavioral measurement or test.
In an embodiment, a therapeutic benefit is recognized when a patient is able
to maintain or
be stabilized in their current state when treated with a therapy protocol of
the present specification.
In an embodiment, a therapeutic benefit is recognized when a patient
maintains/stabilizes
symptoms when treated with a therapy protocol of the present specification
when compared to a
placebo.
In an embodiment, a therapeutic benefit is recognized when a patient shows a
delay or
halting of worsening of symptoms when treated with a therapy protocol of the
present specification
when compared to a placebo.
In an embodiment, a therapeutic benefit is recognized when a patient shows a
delay in the
rate of progression of symptoms when treated with a therapy protocol of the
present specification
when compared to a placebo.
In an embodiment, a therapeutic benefit is recognized when a patient shows an
improvement in symptoms when treated with a therapy protocol of the present
specification when
compared to a placebo.
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In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences a decrease in the accumulation of amyloid plaque in the
perivascular space.
Following are a plurality of non-limiting, exemplary therapeutic endpoints
with reference
to the baseline, starting or initial severity level:
In embodiments, after at least one treatment session or determinable time
period at the end
of which an effect of said at least one therapy treatment is amenable to
measurement, the rate of
progression, level or amount of a patient's physiological and/or cognitive
parameter, is unchanged
relative to the rate, level or amount of that patient's physiological and/or
cognitive parameter
before therapy treatment.
In embodiments, after at least one treatment session or determinable time
period at the end
of which an effect of said at least one therapy treatment is amenable to
measurement, the rate of
progression, level or amount of a patient's physiological and/or cognitive
parameter, is delayed
relative to the rate, level or amount of that patient's physiological and/or
cognitive parameter
before therapy treatment.
In embodiments, after at least one treatment session or determinable time
period at the end
of which an effect of said at least one therapy treatment is amenable to
measurement, the rate of
progression, level or amount of a patient's physiological and/or cognitive
parameter, is modified
relative to the rate of progression, level or amount of that patient's
physiological and/or cognitive
parameter before therapy treatment.
In embodiments, after at least one treatment session or determinable time
period at the end
of which an effect of said at least one therapy treatment is amenable to
measurement, the rate of
progression, level or amount of that patient's physiological and/or cognitive
parameter is improved
relative to the rate of progression, level or amount of that patient's
physiological and/or cognitive
parameter before therapy treatment.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences an improvement of the ADAS-cog score indicative of an
improvement in, or
stabilization of, AD-related symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
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patient experiences an improvement of the CIBIC-plus score indicative of an
improvement in, or
stabilization of, AD-related symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences an improvement of the SIB score indicative of an
improvement in, or
stabilization of, AD-related symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences an improvement of the ADCS-ADL score indicative of an
improvement in, or
stabilization of, AD-related symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences an improvement of the ADCS-ADL-severe score indicative of
an improvement
in, or stabilization of, AD-related symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences an improvement of any one of the global, cognitive,
functional, or behavioral
test scores indicative of an improvement in, or stabilization of, AD-related
symptoms.
In some embodiments, after at least one treatment session or determinable time
period at
the end of which an effect of said at least one treatment session is amenable
to measurement, the
patient experiences a decrease in the accumulation of amyloid plaque in the
perivascular space
indicative of an improvement or stabilization of AD-related symptoms.
FIG. 2 illustrates an exemplary embodiment of a system and its components used
to achieve
the methods of the present specification. The figure depicts an exemplary
basic component flow
diagram defining elements of the HDL modification system 200. Embodiments of
the components
of system 200 are utilized after obtaining a blood fraction from a patient or
another individual
(donor). The plasma, separated from the blood is brought in a sterile bag to
system 200 for further
processing. The plasma may be separated from blood using a known
plasmapheresis device. The
plasma may be collected from the patient into a sterile bag using standard
apheresis techniques.
The plasma is then brought in the form of a fluid input to system 200 for
further processing. In
embodiments, system 200 is not connected to the patient at any time and is a
discrete, stand-along
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system for delipidating plasma. The patient's plasma is processed by system
200 and brought back
to the patient's location to be reinfused back into the patient. In alternate
embodiments, the system
may be a continuous flow system that is connected to the patient in which both
plasmapheresis
and delipidation are performed in an excorporeal, parallel system and the
delipidated plasma
product is returned to the patient.
A fluid input 205 (containing blood plasma) is provided and connected via
tubing to a
mixing device 220. A solvent input 210 is provided and also connected via
tubing to mixing device
220. In embodiments, valves 215, 216 are used to control the flow of fluid
from fluid input 205
and solvent from solvent input 210 respectively. It should be appreciated that
the fluid input 205
contains any fluid that includes HDL particles, including plasma having LDL
particles or devoid
of LDL particles, as discussed above. It should further be appreciated that
solvent input 210 can
include a single solvent, a mixture of solvents, or a plurality of different
solvents that are mixed at
the point of solvent input 210. While depicted as a single solvent container,
solvent input 210 can
comprise a plurality of separate solvent containers. Embodiments of types of
solvents that may be
used are discussed above.
Mixer 220 mixes fluid from fluid input 205 and solvent from solvent input 210
to yield a
fluid-solvent mixture. In embodiments, mixer 220 is capable of using a shaker
bag mixing method
with the input fluid and input solvent in a plurality of batches, such as 1,
2, 3 or more batches. An
exemplary mixer is a Barnstead Labline orbital shaker table. In alternative
embodiments, other
known methods of mixing are utilized. Once formed, the fluid-solvent mixture
is directed, through
tubing and controlled by at least one valve 215a, to a separator 225. In an
embodiment, separator
225 is capable of performing bulk solvent separation through gravity
separation in a funnel-shaped
bag.
In separator 225, the fluid-solvent mixture separates into a first layer and
second layer. The
first layer comprises a mixture of solvent and lipid that has been removed
from the HDL particles.
The first layer is transported through a valve 215b to a first waste container
235. The second layer
comprises a mixture of residual solvent, modified HDL particles, and other
elements of the input
fluid. One of ordinary skill in the art would appreciate that the composition
of the first layer and
the second layer would differ based upon the nature of the input fluid. Once
the first and second
layers separate in separator 225, the second layer is transported through
tubing to a solvent
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extraction device 240. In an embodiment, a pressure sensor 229 and valve 230
is positioned in the
flow stream to control the flow of the second layer to solvent extraction
device 240.
The opening and closing of valves 215, 216 to enable the flow of fluid from
input
containers 205, 210 may be timed using mass balance calculations derived from
weight
determinations of the fluid inputs 205, 210 and separator 225. For example,
the valve 215b
between separator 225 and first waste container 235 and valve 230 between
separator 225 and
solvent extraction device 240 open after the input masses (fluid and solvent)
substantially balances
with the mass in separator 225 and a sufficient period of time has elapsed to
permit separation
between the first and second layers. Depending on what solvent is used, and
therefore which layer
settles to the bottom of separator 225, either valve 215b between separator
225 and first waste
container 235 is opened or valve 230 between separator 225 and solvent
extraction device 240 is
opened. One of ordinary skill in the art would appreciate that the timing of
the opening is
dependent upon how much fluid is in the first and second layers and would
further appreciate that
it is preferred to keep valve 215b between separator 225 and first waste
container 235 open just
long enough to remove all of the first layer and some of the second layer,
thereby ensuring that as
much solvent as possible has been removed from the fluid being sent to solvent
extraction device
240.
In embodiments, an infusion grade fluid ("IGF") may be employed via one or
more inputs
260 which are in fluid communication with the fluid path 221 leading from
separator 225 to solvent
extraction device 240 for priming. In an embodiment, saline is employed as the
infusion grade
priming fluid in at least one of inputs 260. In an embodiment, 0.9% sodium
chloride (saline) is
employed. In other embodiments, glucose may be employed as the infusion grade
priming fluid
in any one of inputs 260.
In embodiments, a glucose input 255 and one or more saline inputs 260 are in
fluid
communication with the fluid path 221 leading from separator 225 to solvent
extraction device
240. A plurality of valves 215c and 215d are also be incorporated in the flow
stream from glucose
input 255 and saline input 260 respectively, to the tubing providing the flow
path 221 from
separator 225 to solvent extraction device 240. IGF such as saline and/or
glucose are incorporated
into embodiments of the present specification in order to prime solvent
extraction device 240 prior
to operation of the system. In embodiments, saline is used to prime most of
the fluid
communication lines and solvent extraction device 240. If priming is not
required, the IGF inputs
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are not employed. Where such priming is not required, the glucose and saline
inputs are not
required. Also, one of ordinary skill in the art would appreciate that the
glucose and saline inputs
can be replaced with other primers if required by the solvent extraction
device 240 requires it.
In some embodiments, solvent extraction device 240 is a charcoal column
designed to
remove the specific solvent used in solvent input 210. An exemplary solvent
extraction device
240 is an Asahi Hemosorber charcoal column, or the Bazter/Gambro Adsorba 300C
charcoal
column or any other charcoal column that is employed in blood hemoglobin
perfusion procedures.
A pump 250 is used to move the second layer from separator 225, through
solvent extraction device
240, and to an output container 245. In embodiments, pump 250 is a rotary
peristaltic pump, such
as a Masterflex Model 77201-62.
The first layer is directed to waste container 235 that is in fluid
communication with
separator 225 through tubing and at least one valve 215b. Additionally, other
waste, if generated,
can be directed from the fluid path connecting solvent extraction device 240
and output container
245 to a second waste container 255. Optionally, in an embodiment, a valve
215f is included in
the path from the solvent extraction device 240 to the output container 245.
Optionally, in an
embodiment, a valve 215g is included in the path from the solvent extraction
device 240 to the
second waste container 255.
In an embodiment of the present specification, gravity is used, wherever
practical, to move
fluid through each of the plurality of components. For example, gravity is
used to drain input
plasma 205 and input solvent 210 into mixer 220. Where mixer 220 comprises a
shaker bag and
separator 225 comprises a funnel bag, fluid is moved from the shaker bag to
the funnel bag and,
subsequently, to first waste container 235, if appropriate, using gravity.
In an additional embodiment, not shown in FIG. 2, the output fluid in output
container 245
is subjected to a solvent detection system, or lipid removing agent detection
system, to determine
if any solvent, or other undesirable component, is in the output fluid. In
embodiments, a solvent
sensor is only employed in a continuous flow system. In one embodiment, the
output fluid is
subjected to sensors that are capable of determining the concentrations of
solvents introduced in
the solvent input, such as n-butanol or di-isopropyl ether. The output fluid
is returned to the
bloodstream of the patient and the solvent concentrations must be below a
predetermined level to
carry out this operation safely. In embodiments, the sensors are capable of
providing such
concentration information on a real-time basis and without having to
physically transport a sample
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of the output fluid, or air in the headspace, to a remote device. The
resultant separated modified
HDL particles are then introduced to the bloodstream of the patient.
In one embodiment, molecularly imprinted polymer technology is used to enable
surface
acoustic wave sensors. A surface acoustic wave sensor receives an input,
through some interaction
.. of its surface with the surrounding environment, and yields an electrical
response, generated by
the piezoelectric properties of the sensor substrate. To enable the
interaction, molecularly
imprinted polymer technology is used. Molecularly imprinted polymers are
plastics programmed
to recognize target molecules, like pharmaceuticals, toxins or environmental
pollutants, in
complex biological samples. The molecular imprinting technology is enabled
by the
polymerization of one or more functional monomers with an excess of a
crosslinking monomer in
presence of a target template molecule exhibiting a structure similar to the
target molecule that is
to be recognized, i.e. the target solvent.
The use of molecularly imprinted polymer technology to enable surface acoustic
wave
sensors can be made more specific to the concentrations of targeted solvents
and are capable of
differentiating such targeted solvents from other possible interferents. As a
result, the presence of
acceptable interferents that may have similar structures and/or properties to
the targeted solvents
would not prevent the sensor from accurately reporting existing respective
solvent concentrations.
Alternatively, if the input solvent comprises certain solvents, such as n-
butanol,
electrochemical oxidation could be used to measure the solvent concentration.
Electrochemical
measurements have several advantages. They are simple, sensitive, fast, and
have a wide dynamic
range. The instrumentation is simple and not affected by humidity. In one
embodiment, the target
solvent, such as n-butanol, is oxidized on a platinum electrode using cyclic
voltammetry. This
technique is based on varying the applied potential at a working electrode in
both the forward and
reverse directions, at a predefined scan rate, while monitoring the current.
One full cycle, a partial
cycle, or a series of cycles can be performed. While platinum is the preferred
electrode material,
other electrodes, such as gold, silver, iridium, or graphite, could be used.
Although, cyclic
voltammetric techniques are used, other pulse techniques such as differential
pulse voltammetry
or square wave voltammetry may increase the speed and sensitivity of
measurements.
Embodiments of the present specification expressly cover any and all forms of
automatically sampling and measuring, detecting, and analyzing an output
fluid, or the headspace
above the output fluid. For example, such automated detection can be achieved
by integrating a
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mini-gas chromatography (GC) measuring device that automatically samples air
in the output
container, transmits it to a GC device optimized for the specific solvents
used in the delipidation
process, and, using known GC techniques, analyzes the sample for the presence
of the solvents.
Referring back to FIG. 2, suitable materials for use in any of the apparatus
components as
described herein include materials that are biocompatible, approved for
medical applications that
involve contact with internal body fluids, and in compliance with U.S. PVI or
ISO 10993 standards.
Further, the materials do not substantially degrade from, for instance,
exposure to the solvents used
in the present specification, during at least a single use. The materials are
sterilizable either by
radiation or ethylene oxide (Et0) sterilization. Such suitable materials are
capable of being formed
into objects using conventional processes, such as, but not limited to,
extrusion, injection molding
and others. Materials meeting these requirements include, but are not limited
to, nylon,
polypropylene, polycarbonate, acrylic, polysulfone, polyvinylidene fluoride
(PVDF),
fluoroelastomers such as VITON, available from DuPont Dow Elastomers L.L.C.,
thermoplastic
elastomers such as SANTOPRENE, available from Monsanto, polyurethane,
polyvinyl chloride
(PVC), polytetrafluoroethylene (PTFE), polyphenylene ether (PFE),
perfluoroalkoxy copolymer
(PFA), which is available as TEFLON PFA from E.I. du Pont de Nemours and
Company, and
combinations thereof.
Valves 215, 215a, 215b, 215c, 215d, 215e, 215f, 215g, 216 and any other valve
used in
each embodiment may be composed of, but are not limited to, pinch, globe,
ball, gate or other
conventional valves. In some embodiments, the valves are occlusion valves such
as Acro
Associates' Model 955 valve. However, the present specification is not limited
to a valve having
a particular style. Further, the components of each system described in
accordance with
embodiments of the present specification may be physically coupled together or
coupled together
using conduits that may be composed of flexible or rigid pipe, tubing or other
such devices known
to those of ordinary skill in the art.
FIG. 3 illustrates an exemplary configuration of a system used in accordance
with some
embodiments of the present specification to achieve the processes disclosed
herein. Referring to
FIG. 3, a configuration of basic components of the HDL modification system 300
is shown. A
fluid input 305 is provided and connected via tubing to a mixing device 320. A
solvent input 310
is provided and also connected via tubing to a mixing device 320. Preferably
valves 316 are used
to control the flow of fluid from fluid input 305 and solvent from solvent
input 310. It should be
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appreciated that the fluid input 305 preferably contains any fluid that
includes HDL particles,
including plasma having LDL particles or devoid of LDL particles, as discussed
above. It should
further be appreciated that solvent input 310 can include a single solvent, a
mixture of solvents, or
a plurality of different solvents that are mixed at the point of solvent input
310. While depicted as
a single solvent container, solvent input 310 can comprise a plurality of
separate solvent containers.
The types of solvents that are used and preferred are discussed above.
The mixer 320 mixes fluid from fluid input 305 and solvent from solvent input
310 to yield
a fluid-solvent mixture. Preferably, mixer 320 is capable of using a shaker
bag mixing method
with the input fluid and input solvent in a plurality of batches, such as 1,
2, 3 or more batches.
Once formed, the fluid-solvent mixture is directed, through tubing and
controlled by at least one
valve 321, to a separator 325. In a preferred embodiment, separator 325 is
capable of performing
bulk solvent separation through gravity separation in a funnel-shaped bag.
In the separator 325, the fluid-solvent mixture separates into a first layer
and second layer.
The first layer comprises a mixture of solvent and lipid that has been removed
from the HDL
particles. The second layer comprises a mixture of residual solvent, modified
HDL particles, and
other elements of the input fluid. One of ordinary skill in the art would
appreciate that the
composition of the first layer and the second layer would differ based upon
the nature of the input
fluid. Once the first and second layers separate in separator 325, the second
layer is transported
through tubing to a solvent extraction device 340. Preferably, a pressure
sensor 326 and valve 327
is positioned in the flow stream to control the flow of the second layer to
the solvent extraction
device 340.
Preferably, a glucose input 330 and saline input 350 is in fluid communication
with the
fluid path leading from the separator 325 to the solvent extraction device
340. A plurality of valves
331 is also preferably incorporated in the flow stream from the glucose input
330 and saline input
350 to the tubing providing the flow path from the separator 325 to the
solvent extraction device
340. Glucose and saline are incorporated into the present specification in
order to prime the solvent
extraction device 340 prior to operation of the system. Where such priming is
not required, the
glucose and saline inputs are not required. Also, one of ordinary skill in the
art would appreciate
that the glucose and saline inputs can be replaced with other primers if the
solvent extraction device
340 requires it.
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The solvent extraction device 340 is preferably a charcoal column designed to
remove the
specific solvent used in the solvent input 310. An exemplary solvent
extraction device 340 is an
Asahi Hemosorber charcoal column. A pump 335 is used to move the second layer
from the
separator 325, through the solvent extraction device 340, and to an output
container 315. The pump
is preferably a peristaltic pump, such as a Masterflex Model 77201-62.
The first layer is directed to a waste container 355 that is in fluid
communication with
separator 325 through tubing and at least one valve 356. Additionally, other
waste, if generated,
can be directed from the fluid path connecting solvent extraction device 340
and output container
315 to waste container 355.
Preferably, an embodiment of the present specification uses gravity, wherever
practical, to
move fluid through each of the plurality of components. For example,
preferably gravity is used
to drain the input plasma 305 and input solvent 310 into the mixer 320. Where
the mixer 320
comprises a shaker bag and separator 325 comprises a funnel bag, fluid is
moved from the shaker
bag to the funnel bag and, subsequently, to the waste container 355, if
appropriate, using gravity.
In general, the present specification preferably comprises configurations
wherein all inputs,
such as input plasma and input solvents, disposable elements, such as mixing
bags, separator bags,
waste bags, solvent extraction devices, and solvent detection devices, and
output containers are in
easily accessible positions and can be readily removed and replaced by a
technician.
To enable the operation of the above described embodiments of the present
specification,
it is preferable to supply a user of such embodiments with a packaged set of
components, in kit
form, comprising each component required to practice embodiments of the
present specification.
The kit may include an input fluid container (i.e. a high density lipoprotein
source container), a
lipid removing agent source container (i.e. a solvent container), disposable
components of a mixer,
such as a bag or other container, disposable components of a separator, such
as a bag or other
container, disposable components of a solvent extraction device (i.e. a
charcoal column), an output
container, disposable components of a waste container, such as a bag or other
container, solvent
detection devices, and, a plurality of tubing and a plurality of valves for
controlling the flow of
input fluid (high density lipoprotein) from the input container and lipid
removing agent (solvent)
from the solvent container to the mixer, for controlling the flow of the
mixture of lipid removing
agent, lipid, and particle derivative to the separator, for controlling the
flow of lipid and lipid
removing agent to a waste container, for controlling the flow of residual
lipid removing agent,
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residual lipid, and particle derivative to the extraction device, and for
controlling the flow of
particle derivative to the output container.
In one embodiment, a kit comprises a plastic container having disposable
components of a
mixer, such as a bag or other container, disposable components of a separator,
such as a bag or
other container, disposable components of a waste container, such as a bag or
other container, and,
a plurality of tubing and a plurality of valves for controlling the flow of
input fluid (high density
lipoprotein) from the input container and lipid removing agent (solvent) from
the solvent container
to the mixer, for controlling the flow of the mixture of lipid removing agent,
lipid, and particle
derivative to the separator, for controlling the flow of lipid and lipid
removing agent to a waste
container, for controlling the flow of residual lipid removing agent, residual
lipid, and particle
derivative to the extraction device, and for controlling the flow of particle
derivative to the output
container. Disposable components of a solvent extraction device (i.e. a
charcoal column), the input
fluid, the input solvent, and solvent extraction devices may be provided
separately.
The above examples are merely illustrative of the many applications of the
system of
present invention. Although only a few embodiments of the present invention
have been described
herein, it should be understood that the present invention might be embodied
in many other specific
forms without departing from the spirit or scope of the invention. Therefore,
the present examples
and embodiments are to be considered as illustrative and not restrictive, and
the invention may be
modified within the scope of the appended claims.
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