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February 15, 1995

Hypotension During Sham Apheresis in a Patient Taking ACE Inhibitors

Author Affiliations

University of Trieste Trieste, Italy

JAMA. 1995;273(7):520-521. doi:10.1001/jama.1995.03520310012008

To the Editor.  —Dr Agishi1 discusses the evidence that anaphylactoid reactions could occur during low-density lipoprotein (LDL) apheresis performed with the dextran sulfate— cellulose (DSC) adsorption columns2 in patients taking angiotensin converting enzyme (ACE) inhibitors.3 This adverse reaction is triggered by the entrapment of the Hageman factor, high-molecular-weight kininogen, and prekallikrein into the DSC column, leading to kallikrein activation and bradykinin generation. Bradykinin is usually inactivated rapidly by kinases I and II,3 which are identical to ACE and are inhibited by ACE inhibitors. Therefore, increased generation and decreased catabolism of bradykinin may explain this adverse reaction during the LDL apheresis.Recently, we observed a case of hypotension in a patient treated with an ACE inhibitor during an LDL-apheretic procedure without the DSC column (sham apheresis). After obtaining informed consent, we routinely perform sham apheresis in candidates for chronic LDL apheresis to check its feasibility (eg, adequate

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