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Severe life-threatening anaphylactoid reactions during low-density lipoprotein apheresis (LDL-A) with dextran sulphate have been reported in patients receiving angiotensin-converting enzyme (ACE) inhibitors. On the other side, several reports showed angiotensin II receptor blockers (ARB) are a safe alternative to ACE inhibitors. But we had a 79-year-old women receiving ARB (Losartan 100mg/day) who suffered from anaphylactic shock during LDL-A with dextran sulphate. Heparin was used as an anticoagulant. There were no anaphylactoid reactions and no complications during LDL-A therapies when we tried LDL-A using nafamostat mesilate (FUT) or dalteparin sodium (DA) instead of heparin. Plasma bradykinin (p-BK) levels were measured on the four points of pre-LDL-A, before and after the column after 1, 000ml of plasma treatment and post-LDL-A in the presence of FUT or DA. As a result, during apheresis with DA, p-BK level was markedly increased after the column after 1, 000ml of plasma treatment. Conversely, p-BK level was almost unchanged during apheresis with FUT. It was speculated that the p-BK level on the use of heparin would be also markedly increased in this case. We recommend that FUT be used as an anticoagulant instead of heparin for the patient treated with LDL apheresis with ARB.
