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Abstract: SA-PO437

Anaphylaxis From Ethylene Oxide Sterilized Dialysis Tubing and Needles

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Crane, Clarkson, University of California San Diego, La Jolla, California, United States
  • Cunard, Robyn A., University of California San Diego, La Jolla, California, United States
  • Scanlon, Nicholas, University of California San Diego, La Jolla, California, United States
  • Doherty, Taylor, University of California San Diego, La Jolla, California, United States
  • Potok, O. Alison, University of California San Diego, La Jolla, California, United States
Introduction

Hypersensitivity reactions to ethylene oxide (EtO) sterilized dialyzers have been described. While EtO is no longer used to sterilize most dialyzers, it is used on other pieces of dialysis equipment. We present a case of dialysis-related anaphylaxis attributed to an IgE-mediated allergy to EtO-sterilized dialysis tubing and needles.

Case Description

A 78-year-old male with end stage kidney disease (ESKD) was maintained on hemodialysis (HD) for 3 years without complications. Access was a tunneled dialysis catheter (TDC) then transitioned to an arteriovenous fistula (AVF).

Subsequent treatments were complicated by intradialytic hypotension and syncope within minutes of starting HD. Symptoms also included pruritis (no hives), and a throat closure sensation; Labs showed WBC of 11.3 k/uL, of which 2.4 K/uL esoinophils. Differential diagnosis included idiopathic hypereosinophilic syndrome (HES), mastocytosis with eosinophilia, mast cell activation syndrome (MCAS), and type 1 hypersensitivity reaction to ethylene oxide (EtO). Workup showed normal cardiac evaluation, negative D816V mutation, negative FIP1L1-PDGFRA, elevated tryptase 28 mcg/L, total IgE >3000 IU/mL, and anti-EtO IgE >100 kU/L.

Access was transitioned back to the TDC and a Revaclear dialyzer (polyaryl sulfone) was used with normal saline rinses of dialysis tubing. He was given prednisone and anti-histamines and tolerated subsequent HD treatments. Prednisone was tapered and omalizumab (anti-IgE Fc) was started.

Discussion

This case is an example of dialysis-associated anaphylaxis initially presenting as intradialytic hypotension. Upon recognition of the hypereosinophilia, it was noted this was chronic since HD initiation 3 years prior. Previous work-up was negative for parasite infections and malignancy, making mastocytosis less likely.

We hypothesize the patient’s eosinophilia and hypersensitivity began upon his initial exposure to EtO and HD equipment. While using a TDC, chronic eosinophilia may have been related to the low-level EtO exposure from saline-rinsed tubing. When use of the AVF with EtO-sterilized needles was resumed, he was exposed to a higher “dose” of EtO. This triggered a more robust type 1 hypersensitivity leading to mast cell degranulation and repeated anaphylactic episodes that were overcome by pretreating with steroids, anti-histamines, and anti-IgE Fc monoclonal, omalizumab.