Letter to the Editor
Hypersensitivity reactions in hemodialysis secondary to synthetic membranes
Reacciones de hipersensibilidad en hemodiálisis secundarias a membranas sintéticas
Vanesa García Chumillas
, María Ramírez Gómez, Ana Delgado Ureña
Corresponding author
Hospital Universitario San Cecilio, Granada, Spain
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She started haemodialysis one year earlier through an arteriovenous fistula using Polyflux® 170H dialyser (polyarylethersulphone, polyvinylpyrrolidone [PVP] and steam-sterilised polyamide mixture) and ultrapure dialysis fluid in a peripheral centre. She was referred to the hospital for episodes of symptomatic hypotension in the last 60<span class="elsevierStyleHsp" style=""></span>min of the session with no response to IV hydration therapy. Haemodialysis was performed with Helixona®plus FX-80 dialyser (steam-sterilised high-flux polysulphone) and minimal ultrafiltration rate, with clinical symptoms returning 120<span class="elsevierStyleHsp" style=""></span>min after the start of the session. A cardiac cause was ruled out by electrocardiogram and transthoracic echocardiography. Laboratory tests showed normal cardiac enzymes, but severe eosinophilia and mild thrombocytopenia. The patient had no history of allergy or known previous eosinophilia. Causes of hypersensitivity during dialysis were ruled out, such as the use of angiotensin-converting enzyme inhibitors, sterilants (ethylene oxide), the presence of endotoxins in the dialysis fluid (negative cultures) and reactions to latex, intravenous iron (without clinical changes after discontinuation) and heparin (negative antiheparin antibodies). Basal serum tryptase levels were elevated. A new dialysis session was performed with NF-2.1U® dialyser (polymethylmethacrylate sterilised by gamma rays) and pre-dialysis medication was administered with antihistamines and corticoids, which were well tolerated. In the successive sessions, the new dialyzer was maintained and the medication was gradually reduced until it was discontinued, appreciating a progressive decrease in eosinophilia until its restoration and absence of symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Dialysis membranes can be classified according to their composition into cellulose, modified cellulose and synthetic membranes. Despite their higher degree of biocompatibility, synthetic membranes are more often associated with hypersensitivity reactions. These usually appear during the first week of dialyser exposure in half of the cases, although cases have been reported 36 months later. Symptoms manifest in up to 66.67% of cases in the first 30<span class="elsevierStyleHsp" style=""></span>min of the session or at any time during the session.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore, the diagnostic difficulty lies in those patients with late onset of symptoms. Eosinophilia and hypoxia are common, and thrombocytopenia, hypocomplementemia or elevated serum tryptase may also occur. Hypersensitivity reactions to different synthetic membranes such as polysulphone, polyethersulphone, polyarylethersulphone, polynephrone and polyacrylonitrile,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> associated with the use of PVP (allergenic substance used to hydrophilise the membrane), have been described in the medical literature. They tend to disappear when switching to a cellulose membrane without PVP, such as cellulose triacetate. Polysulphone membranes are the most commonly used and the ones that most often generate hypersensitivity reactions, as they adsorb proteins that contribute to complement activation, leukocyte adhesion and blood coagulation. However, synthetic polymethylmethacrylate membranes cause less complement activation and may be an alternative alongside cellulose triacetate membranes in cases such as the one described above.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The causality algorithm of Naranjo et al. was applied to the suspected adverse reaction related to the use of membranes containing PVP, confirming such reaction as definitive, since there is a temporal sequence; resolution is complete when exposure is discontinued and returns with other similar membranes together with the complete resolution when the membrane is replaced by a less allergenic material.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, this is a difficult entity to diagnose and should be suspected in patients on haemodialysis using dialysers with synthetic membranes who present with acute or chronic intra-dialysis symptoms unexplained by other causes, with the presence of eosinophilia, hypocomplementemia or increased serum tryptase being useful in the differential diagnosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anaphylaxis from the product(s) of ethylene oxide gas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. 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