Abstract: PO0904
Anaphylaxis Secondary to Citric Acid Allergy in ESKD Patients
Session Information
- Fluid, Electrolytes, and Clinical Events with Dialysis: Getting to the "Heart" of the Matter
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Iftikhar, Hassaan, Washington University in St Louis, St Louis, Missouri, United States
- Jarad, George, Washington University in St Louis, St Louis, Missouri, United States
Introduction
Dialysis reactions are common in ESKD patients undergoing hemodialysis (HD). We report first case of anaphylaxis related to citric acid solution used for dialysis disinfection & descaling.
Case Description
61-year-old male with history of ESKD on HD for 7 years, presented after missing dialysis. Patient underwent urgent HD upon presentation and developed signs of angioedema within first 30 minutes, requiring nasal intubation & treatment with epinephrine, steroids & antihistamine. While intubated and hypotensive, patient had uneventful Slow Low Efficiency Dialysis. Angioedema was presumed secondary to antiemetics, which patient required due to severe nausea shortly after starting HD. Post extubation, patient developed similar reaction with milder symptoms with HD that responded to stopping HD and medical therapy. He had normal complement and mildly elevated tryptase. He was presumed to have a dialyzer reaction therefore, the dialyzer was changed from Revaclear to REXEED & it was tolerated well. He had similar severe reaction a week later while using the REXEED dialyzer. Investigations showed elevated anti-ethylene oxide antibodies (ETO) but clinical significance was questionable given the reaction only developed in inpatient setting. Later we discovered that dialysis machines are disinfected/descaled differently between inpatient & outpatient dialysis, even though both utilize citric acid, which might have led to more exposure to citric acid solution in inpatient setting. For next 2 weeks, patient was dialyzed using different combinations of dialysis machines, dialyzer & dialysis circuits including ones sterilized with ETO, however, all machines were disinfected/descaled using a combination of bleach & heat. After elimination of citric acid, patient had no further anaphylactic reaction.
Discussion
Dialyzer membrane reactions have been commonly described as Type A reactions mediated by dialyzer membrane (IgE mediated) and Type B membrane reactions mediated by complement activation. In our case clinical significance of ETO antibody was not clear, & angioedema was eliminated after removing citric acid from the machine disinfection process. Industrial citric acid mediated angioedema has not been reported before, & it might be an important mediator of allergy in ESRD, & careful review of the dialysis machine preparation should be reviewed in every case of severe allergic reaction.