title: Acute hypotensive transfusion reaction during liver transplantation in a patient on angiotensin converting enzyme inhibitors from low aminopeptidase P activity.
abstract: Acute hypotensive transfusion reactions are newly characterized transfusion reactions in which hypotension is the prominent feature. The pathophysiology of acute hypotensive transfusion reactions is related to the bradykinin function and its metabolism. A liver transplant recipient on treatment with an angiotensin converting enzyme inhibitor developed sudden hypotension, that is, systolic pressure of 60 mm Hg, after receiving 200 mL of a blood product mixture without significant surgical blood loss. He responded to the resuscitation measure, although hypotension developed again after a challenge transfusion of 200 mL of the blood mixture. A severe hypotensive reaction to the blood transfusion and diffuse bleeding from the dissection surfaces forced the transplantation to be aborted after the common bile duct had been divided. We hypothesized that the patient had an acute hypotensive transfusion reaction due to disordered bradykinin metabolism. Analysis of his blood showed low levels of both angiotensin converting enzyme and aminopeptidase P enzyme activity, confirming that the patient experienced an acute hypotensive transfusion reaction that was due to the use of the angiotensin converting enzyme inhibitor and was precipitated by an abnormality in the metabolic enzyme pathway. It is recommended to discontinue angiotensin converting enzyme inhibitors and switch to a different class of antihypertensive medications for patients with a high Model for End-Stage Liver Disease score on the waiting list for liver transplantation.
authors.affiliation: Division of Transplantation, Department of Surgery, Jefferson Medical College-Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA. cataldo.doria@jefferson.edu
authors.forename: Cataldo
authors.initials: C
authors.lastname: Doria
authors.forename: Elia S
authors.initials: ES
authors.lastname: Elia
authors.forename: Yoogoo
authors.initials: Y
authors.lastname: Kang
authors.forename: Albert
authors.initials: A
authors.lastname: Adam
authors.forename: Anik
authors.initials: A
authors.lastname: Desormeaux
authors.forename: Carlo
authors.initials: C
authors.lastname: Ramirez
authors.forename: Adam
authors.initials: A
authors.lastname: Frank
authors.forename: Fabrizio
authors.initials: F
authors.lastname: di Francesco
authors.forename: Jay H
authors.initials: JH
authors.lastname: Herman
mesh_terms: D000208:Acute Disease; D000626:Aminopeptidases / Q000097:blood*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects*; D000959:Antihypertensive Agents / Q000009:adverse effects*; D001794:Blood Pressure; D015536:Down-Regulation; D017809:Fatal Outcome; D006801:Humans; D007022:Hypotension / Q000139:chemically induced / Q000201:enzymology / Q000209:etiology* / Q000503:physiopathology; D017093:Liver Failure / Q000201:enzymology / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D065227:Transfusion Reaction; D017211:Treatment Failure
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D000626:Aminopeptidases; C022750:X-Pro aminopeptidase