MAUDE Adverse Event Report: KANEKA CORPORATION LIPOSORBER LA-15 SYSTEM

Model Number	LA-15
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Sepsis (2067); Urinary Tract Infection (2120)
Date of Event	04/25/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
The information for this case was collected in the post-approval study (treatment of drug-resistant adult and pediatric primary focal segmental glomerulosclerosis using the liposorber? la-15 system).Site reported the patient had the saes on (b)(6) 2023 after the last treatment given on (b)(6), 2022, which was learned during the 12months followup visit on (b)(6) 2023.Site reported patient had sepsis, colstridium difficile, e.Coli, urinary tract infection.Patient was hospitalized from (b)(6)2023 and given cefuroxime, vancomycin, ceftriaxone.The event occurred over ten months after the last liposorber treatment.The sae was determined by the physician to be unrelated to liposorber treatment.
Additional Manufacturer Narrative
The device history records (dhr) of the device concerned was reviewed.The production lot, to which the device concerned belongs, passed all in-process inspections test.No nonconformity or abnormality in the manufacturing processes of the device concerned was found.The actual device was not returned and could not be investigated.The treatment with our product was performed and completed without problems and without product failure.The sae of reported patient's health condition was found during 12 months follow up, which occurred over ten months after the last liposorber treatment.Also, we received a comment from the doctor in charge that there was no causal relationship between the adverse event and our product.As a result of the above, we think that the adverse event was caused by the patient's condition and that there is no causal relationship between the adverse event and our product.Reason for submission: we performed a detailed investigation of the patient's medical history and hospital treatment process and collected sufficient additional information to confirm that there was no device failure, no problem with the dhr, and that a causal relationship was ruled out as a physician's comment in charge.As the manufacturer, we had determined on (b)(6) 2023, in accordance with our procedures, that there was no causal relationship with our product and that the mdr was not applicable.However, at the fda audit received on (b)(6) 2025, the auditor in charge advised us to submit an mdr with the statement "as a manufacturer, we have determined that there is no causal relationship" and we are submitting this mdr.

• Brand Name: LIPOSORBER LA-15 SYSTEM
• Common Device Name: LA-15
• Manufacturer (Section D): KANEKA CORPORATION; 2-3-18; nakanoshima, kita-ku; osaka-city, osaka 530-8 288; JA 530-8288
• Manufacturer (Section G): KANEKA CORPORATION OSAKA PLANT; 5-1-1; torikai-nishi; settsu-city, osaka 566-0 072; JA 566-0072
• Manufacturer Contact: joji sengoku ; 1-12-32; akasaka; minato-ku, tokyo 107-6-028 ; JA 107-6028
• MDR Report Key: 21400185
• Report Number: 3002808904-2025-00006
• Device Sequence Number: 8235332
• Product Code: PBN
• UDI-Device Identifier: 14993478010110
• UDI-Public: 14993478010110
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: P910018
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 07/05/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 10/28/2024
• Device Model Number: LA-15
• Device Lot Number: LAP1599
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/05/2023
• Initial Report FDA Received Date: 02/18/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 11/12/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: MA-03 (SERIAL NO.: (B)(6)).; PLASMA SEPARATOR SULFLUX KP-05 (LOT NO.: FL1A1K).; TUBING NK-M3R(U) (LOT NO.: 21022).
• Outcome Attributed to Adverse Event: Hospitalization
• Patient Age: 26 YR
• Patient Sex: Female