Hemodialysis: Acute Complications - Anaphylactic/Anaphylactoid Reactions

Does this patient have anaphylactic/anaphylactoid reaction?

Symptoms and signs usually develop within first 5 minutes after starting dialysis

Rhinorrhea
Sneezing
Coughing
Lacrimation
Burning or heat throughout body or vascular access site
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Flushing
Pruritus
Nausea/vomiting
Abdominal pain
Diarrhea
Agitation
Chest pain or chest discomfort
Dyspnea
Angioedema
Laryngeal edema
Paresthesias involving fingers, toes, lips, or tongue
Hypotension
Sudden cardiac arrest

Causes

Ethylene oxide (ETO) from manufacturer’s dialyzer sterilant (dialyzer first-use reaction)
Formaldehyde (germicide) retained in dialyzer following disinfection (dialyzer reuse reaction)
Peracetic acid/hydrogen peroxide (Renalin, germicide) retained in dialyzer following disinfection (dialyzer reuse reaction)
Bradykinin release (observed in patients receiving angiotensin II converting enzyme [ACE] inhibitor) and using either

An AN69 dialyzer

A reused dialyzer (usually with peracetic acid/hydrogen peroxide)
Histamine release following exposure to:

Iron dextran

Desferoxamine (rare)

Heparin (rare)

What tests to perform?

CBC – Hypereosinophilia
Serum immunoglobulin – increased IgE level
ETO radioallergosorbent test (RAST) IgE antibody (dialyzer first use reaction)
Formaldehyde test (dialyzer reuse reaction)

How should patients with anaphylactic/anaphylactoid reactions be managed?

Acute management

Stop dialysis
Do not re-infuse extracorporeal blood
Epinephrine
Corticosteroids
Antihistamines
Intubation for acute respiratory failure/arrest

Prevention

Adequate rinsing techniques for both new and reused dialyzers
Use of steam-sterilized, gamma-irradiated- or electron-beam-sterilized dialyzer
Avoidance of AN69 dialyzer or Renalin reused dialyzer in patients receiving ACE inhibitor
Test-dose iron dextran (resuscitative medications should be available)
Use iron sucrose as an alternative to iron dextran

What happens to patients with anaphylactic/anaphylactoid reactions?

Risk of death if unrecognized or treatment delayed

How to utilize team care?

1. Specialty consultations – Call 911 (free-standing dialysis facility) or code team (hospital-based dialysis facility) if sudden cardiac arrest.

2. Nurses – Monitoring of patients with history of atopy, eosinophilia and those prescribed ACE inhibitors.

Are there clinical practice guidelines to inform decision making?

Applications

2006 Clinical practice guidelines for anemia in chronic kidney disease (Published by National Kidney Foundation, K/DOQI)

2008 Emergency treatment of anaphylactic reactions-guidelines for healthcare providers (Published by Resuscitation Council UK)

Limitations – paucity of data on management of anaphylaxis in dialysis patients

Other considerations

ICD-10-CM diagnosis code T78.2: Anaphylactic shock, unspecified

What is the evidence?

“KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease”. Am J Kidney Dis. vol. 47. 2006. pp. S11-145.

Soar, J, Pumphrey, R, Cant, A, Clarke, S, Corbett, A, Dawson, P, Ewan, P, Foëx, B, Gabbott, D, Griffiths, M, Hall, J, Harper, N, Jewkes, F, Maconochie, I, Mitchell, S, Nasser, S, Nolan, J, Rylance, G, Sheikh, A, Unsworth, DJ, Warrell, D. “Working Group of the Resuscitation Council (UK). Emergency treatment of anaphylactic reactions–guidelines for healthcare providers”. Resuscitation. vol. 77. 2008. pp. 157-69.

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Hemodialysis: Acute Complications – Anaphylactic/Anaphylactoid Reactions