Letter to the Editor
Sustained severe intestinal edema after nafamostat mesilate-associated anaphylactic reaction during hemodialysis
Edema intestinal grave y prolongado después de reacción anafiláctica relacionada con nafamostat mesilato durante la hemodiálisis
Mitsutoshi Shindo, Susumu Ookawara
, Taisuke Kitano, Hiroki Ishii, Haruhisa Miyazawa, Kiyonori Ito, Yuichiro Ueda, Keiji Hirai, Taro Hoshino, Yoshiyuki Morishita
Corresponding author
Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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array:2 [ "paginaInicial" => "202" "paginaFinal" => "204" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mitsutoshi Shindo, Susumu Ookawara, Taisuke Kitano, Hiroki Ishii, Haruhisa Miyazawa, Kiyonori Ito, Yuichiro Ueda, Keiji Hirai, Taro Hoshino, Yoshiyuki Morishita" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Mitsutoshi" "apellidos" => "Shindo" ] 1 => array:4 [ "nombre" => "Susumu" "apellidos" => "Ookawara" "email" => array:1 [ 0 => "su-ooka@hb.tp1.jp" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Taisuke" "apellidos" => "Kitano" ] 3 => array:2 [ "nombre" => "Hiroki" "apellidos" => "Ishii" ] 4 => array:2 [ "nombre" => "Haruhisa" "apellidos" => "Miyazawa" ] 5 => array:2 [ "nombre" => "Kiyonori" "apellidos" => "Ito" ] 6 => array:2 [ "nombre" => "Yuichiro" "apellidos" => "Ueda" ] 7 => array:2 [ "nombre" => "Keiji" "apellidos" => "Hirai" ] 8 => array:2 [ "nombre" => "Taro" "apellidos" => "Hoshino" ] 9 => array:2 [ "nombre" => "Yoshiyuki" "apellidos" => "Morishita" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Edema intestinal grave y prolongado después de reacción anafiláctica relacionada con nafamostat mesilato durante la hemodiálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 495 "Ancho" => 1406 "Tamanyo" => 88446 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Pelvic computed tomography scan at the level of the sigmoid colon. Remarkable mucosal edema was confirmed in the circumference of the sigmoid colon. (b) Abdominal and pelvic computed tomography scan (coronal view) showing severe whole-intestine edema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anticoagulant use is essential to safe hemodialysis (HD) therapy because it prevents thrombosis in the extracorporeal circuit. For HD therapy in Japan, nafamostat mesilate (NM) is usually used during HD in patients with a tendency to bleed because of its short half-life.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However, NM use is reportedly associated with adverse effects, including hyperkalemia,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> agranulocytosis,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and anaphylactic reaction.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> A recent report indicated the development of anaphylactic shock in HD patients who received NM.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Here, we report a case of NM-associated anaphylactic reaction in a patient on HD, followed by severe intestinal edema.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 64-year-old man with diabetes mellitus and a 5-year history of HD was admitted to our hospital for body-fluid status evaluation because of a recent episode of intradialytic hypotension at his dialysis facility. The intradialytic hypotension was suspected to be associated with ultrafiltration-induced hypovolemia during HD before admission. NM was used several times instead of heparin sodium for retinal bleeding complicated by diabetes mellitus in his dialysis facility. At our dialysis center, HD was performed in the same manner using NM. We carefully monitored for the occurrence of ultrafiltration-induced intradialytic hypotension. His blood pressure (BP) was 195/90<span class="elsevierStyleHsp" style=""></span>mmHg before HD but rapidly decreased to 114/56<span class="elsevierStyleHsp" style=""></span>mmHg. The arterial oxygen saturation measured by pulse oximetry (SpO<span class="elsevierStyleInf">2</span>) was 88% with dyspnea and deterioration of consciousness shortly after the HD initiation. Based on the clinical course from before admission to this episode, intradialytic hypotension with NM-associated anaphylactic reaction was diagnosed. At a later date, specific immunoglobulin E (IgE) antibodies to NM were detected in his blood. The HD therapy was discontinued to avoid further worsening of his systemic circulation. Although his BP recovered and his symptoms disappeared after HD was discontinued, he suffered from mild abdominal tenderness after the anaphylactic reaction; therefore, contrast computed tomography of the abdomen and pelvis was performed, which revealed remarkable mucosal edema at a circumference of the sigmoid colon (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a) and along the entire intestine on a coronal view (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). During the next HD session using low-molecular-weight heparin, the intradialytic hypotension completely disappeared; thereafter, HD was safely performed. However, because the intestinal edema persisted on lower gastrointestinal endoscopy 2 weeks after the reaction, total parenteral nutrition instead of solid and liquid foods was necessary for approximately 3 weeks. Thereafter, he ate normally without worsening of the intestinal edema and fully recovered after 1 month of treatment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An anaphylactic reaction usually occurs by an IgE-dependent immunologic mechanism and is commonly triggered by foods, stinging insect venom, and medications through acute onset within minutes to several hours. Furthermore, its reaction frequently increases vascular permeability, which increases the risk of death due to fluid extravasation with resultant sequential decreases in circulating blood volume, venous return, and BP.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Interestingly, the increase in vascular permeability induced by the anaphylactic reaction differs among systemic organs, and the extent of vascular permeability changes vary considerably among tissues: vascular permeability increases markedly in the trachea, moderately in the mesentery and intestines, and slightly in the other organs.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In this case, the whole-intestine edema associated with increased vascular permeability was surprisingly remarkable compared to other systemic organs in the NM-associated anaphylactic reaction, although the presence of tracheal edema might be suspected because of his respiratory distress and the SpO<span class="elsevierStyleInf">2</span> decrease at the reaction's onset. In addition to the intestinal edema, it was interesting that improvement of the intestinal edema and dysfunction took several weeks. The reason for the difference between the rapid improvement of the circulating status and respiratory distress and the sustained gastrointestinal symptoms, including intestinal edema, in this case remains unclear. However, reports to date of the association between NM-associated anaphylactic reactions and remarkable intestinal edema are scarce. Therefore, this case report is relevant and showed that we should carefully monitored the systemic vascular permeability increase caused by the anaphylactic reaction, particularly in the intestine, in patients in whom NM is used during HD.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In Japan, the use of NM as an anticoagulant during blood purification is recommended in patients with various hemorrhagic complications as it has a lower risk of hemorrhage.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However, in patients with a history of NM-induced allergic reactions, low-molecular-weight heparin is usually administered instead of NM.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In this case, HD was performed without worsening of the retinal bleeding after switching to low-molecular-weight heparin. Furthermore, rinsing the dialysis circuit with heparin and albumin<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and introducing a regional citrate infusion into the circuit<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> have recently shown good survival of the extra corporeal circuit without increasing the bleeding risk. Therefore, HD may have been better performed using these methods to avoid the occurrence of the NM-associated anaphylactic reaction.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, our experience described here suggests that patients administered NM during HD because of hemorrhagic complications should be carefully observed for anaphylactic reaction including BP reduction, respiratory distress, and intestinal edema via increased vascular permeability.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:2 [ "identificador" => "xack404357" "titulo" => "Acknowledgement" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 495 "Ancho" => 1406 "Tamanyo" => 88446 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Pelvic computed tomography scan at the level of the sigmoid colon. 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Kurata" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Allergy Asthma Immunol Res" "fecha" => "2018" "volumen" => "10" "paginaInicial" => "52" "paginaFinal" => "61" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heparin and albumin as part of the priming solution limits exposure to anticoagulation during hemodialysis: in vitro studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Kyrk" 1 => "A. Bechara" 2 => "M. Skagerlind" 3 => "B. Stegmayr" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Artif Organs" "fecha" => "2014" "volumen" => "37" "paginaInicial" => "734" "paginaFinal" => "740" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regional citrate anticoagulation in hemodialysis: an observational study of safety, efficacy, and effect on calcium balance during routine care" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.F. Singer" 1 => "O. Williams" 2 => "C. Mercado" 3 => "B. Chen" 4 => "G. Talaulikar" 5 => "G. Walters" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Can J Kidney Health Dis" "fecha" => "2016" "volumen" => "3" "paginaInicial" => "22" "itemHostRev" => array:3 [ "pii" => "S0091674908018538" "estado" => "S300" "issn" => "00916749" ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack404357" "titulo" => "Acknowledgement" "texto" => "<p id="par0035" class="elsevierStylePara elsevierViewall">We thank our hospital's dialysis staff members.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003900000002/v1_201904270637/S2013251419300434/v1_201904270637/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003900000002/v1_201904270637/S2013251419300434/v1_201904270637/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251419300434?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 7 | 14 |
| 2024 October | 44 | 52 | 96 |
| 2024 September | 58 | 40 | 98 |
| 2024 August | 79 | 53 | 132 |
| 2024 July | 48 | 36 | 84 |
| 2024 June | 68 | 38 | 106 |
| 2024 May | 69 | 37 | 106 |
| 2024 April | 49 | 34 | 83 |
| 2024 March | 36 | 29 | 65 |
| 2024 February | 30 | 36 | 66 |
| 2024 January | 28 | 23 | 51 |
| 2023 December | 24 | 23 | 47 |
| 2023 November | 35 | 33 | 68 |
| 2023 October | 26 | 32 | 58 |
| 2023 September | 22 | 26 | 48 |
| 2023 August | 24 | 25 | 49 |
| 2023 July | 35 | 25 | 60 |
| 2023 June | 31 | 17 | 48 |
| 2023 May | 34 | 32 | 66 |
| 2023 April | 21 | 17 | 38 |
| 2023 March | 37 | 19 | 56 |
| 2023 February | 29 | 14 | 43 |
| 2023 January | 29 | 25 | 54 |
| 2022 December | 45 | 27 | 72 |
| 2022 November | 43 | 26 | 69 |
| 2022 October | 41 | 31 | 72 |
| 2022 September | 34 | 33 | 67 |
| 2022 August | 37 | 38 | 75 |
| 2022 July | 29 | 45 | 74 |
| 2022 June | 20 | 41 | 61 |
| 2022 May | 55 | 27 | 82 |
| 2022 April | 35 | 40 | 75 |
| 2022 March | 31 | 42 | 73 |
| 2022 February | 32 | 37 | 69 |
| 2022 January | 49 | 39 | 88 |
| 2021 December | 40 | 41 | 81 |
| 2021 November | 41 | 36 | 77 |
| 2021 October | 46 | 39 | 85 |
| 2021 September | 24 | 27 | 51 |
| 2021 August | 43 | 31 | 74 |
| 2021 July | 53 | 33 | 86 |
| 2021 June | 40 | 22 | 62 |
| 2021 May | 98 | 47 | 145 |
| 2021 April | 153 | 47 | 200 |
| 2021 March | 64 | 26 | 90 |
| 2021 February | 41 | 37 | 78 |
| 2021 January | 25 | 16 | 41 |
| 2020 December | 39 | 15 | 54 |
| 2020 November | 25 | 15 | 40 |
| 2020 October | 15 | 24 | 39 |
| 2020 September | 26 | 10 | 36 |
| 2020 August | 23 | 16 | 39 |
| 2020 July | 13 | 10 | 23 |
| 2020 June | 22 | 18 | 40 |
| 2020 May | 25 | 12 | 37 |
| 2020 April | 17 | 13 | 30 |
| 2020 March | 19 | 10 | 29 |
| 2020 February | 11 | 16 | 27 |
| 2020 January | 22 | 32 | 54 |
| 2019 December | 21 | 17 | 38 |
| 2019 November | 15 | 15 | 30 |
| 2019 October | 14 | 4 | 18 |
| 2019 September | 11 | 19 | 30 |
| 2019 August | 17 | 12 | 29 |
| 2019 July | 19 | 24 | 43 |
| 2019 June | 21 | 22 | 43 |
| 2019 May | 23 | 22 | 45 |
| 2019 April | 8 | 10 | 18 |
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