PS-R05-4: PREVENTION OF HYPOTENSION DURING LDL-APHERESIS BY NAFAMOSTAT MESYLATE: A CASE REPORT

Abstract

Objectives: The prevalence of peripheral artery disease (PAD) is high in hemodialysis patients and has a poor prognosis. More than 10,000 hemodialysis patients require lower-extremity amputation. LDL-apheresis has been initiated as a supportive treatment for patients with chronic limb-threatening ischemia (CLTI), especially in cases where revascularization by endovascular therapy (EVT) is not sufficiently effective. In 2021, a new adsorption-type blood purification device, Rheocana, that can selectively remove LDL-C and fibrinogen, was developed. In a clinical trial, 45.9% of the ulcers were healed using Rheocana. Since then, it has been widely used for dialysis patients with CLTI in Japan; however, hypotension during LDL-apheresis is still a major adverse event. Design and Methods: Case report. Results: An 83-year-old Japanese man presented with a right leg ulcer. He had started undergoing hemodialysis 3 years prior because of diabetic kidney disease. CLTI was recognized 6 months prior, and repeated EVT was ineffective and failed to improve the ulcer. His blood pressure was 129/71 mmHg and antihypertensive agents were not used. LDL-apheresis with Rheocana was initiated; however, his systolic blood pressure decreased to 60 mmHg, and LDL-apheresis was stopped immediately. After discontinuing LDL-apheresis, the his blood pressure recovered. Anticoagulants were changed from heparin to nafamostat mesylate, and LDL-apheresis was restarted. His blood pressure did not decrease after anticoagulation therapy, and his leg ulcer was successfully healed. Conclusion: During LDL-apheresis, factor VIII and kallikrein are activated when the plasma comes in contact with the negatively charged dextran surface, resulting in a decrease in blood pressure by promoting bradykinin production. And thus, in case of ACEI use is contraindicated. Nafamostat mesylate is thought to reduce bradykinin production by suppressing kallikrein. Blood pressure often decreases by approximately 30 mmHg when LDL-apheresis is started; however, nafamostat mesylate was dramatically effective in preventing decrease in blood pressure. Nafamostat mesylate should be used in patients with CLTI and low blood pressure.