Letter to the Editor: Brief clinical experiences
Reaction to synthetic membranes in hemodialysis
Reacción a membranas sintéticas en hemodiálisis
Silvia González Sanchidrián
, Pedro Jesús Labrador Gómez, Jesús Pedro Marín Álvarez, María Carmen Jiménez Herrero, Inés Castellano Cerviño, Sandra Gallego Domínguez, José María Sánchez-Montalbán, Javier Deira Lorenzo, Elena Davin Carrero, Santiago Polanco Candelario, Juan Ramón Gómez-Martino Arroyo
Corresponding author
Servicio de Nefrología, Hospital San Pedro de Alcántara, Complejo Hospitalario de Cáceres, Cáceres, Spain
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Candelario, Juan Ramón Gómez-Martino Arroyo" "autores" => array:11 [ 0 => array:4 [ "nombre" => "Silvia" "apellidos" => "González Sanchidrián" "email" => array:1 [ 0 => "silvia_goz@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Pedro Jesús" "apellidos" => "Labrador Gómez" ] 2 => array:2 [ "nombre" => "Jesús Pedro" "apellidos" => "Marín Álvarez" ] 3 => array:2 [ "nombre" => "María Carmen" "apellidos" => "Jiménez Herrero" ] 4 => array:2 [ "nombre" => "Inés" "apellidos" => "Castellano Cerviño" ] 5 => array:2 [ "nombre" => "Sandra" "apellidos" => "Gallego Domínguez" ] 6 => array:2 [ "nombre" => "José María" "apellidos" => "Sánchez-Montalbán" ] 7 => array:2 [ "nombre" => "Javier" "apellidos" => "Deira Lorenzo" ] 8 => array:2 [ "nombre" => "Elena" "apellidos" => "Davin Carrero" ] 9 => array:2 [ "nombre" => "Santiago" "apellidos" => "Polanco Candelario" ] 10 => array:2 [ "nombre" => "Juan Ramón" "apellidos" => "Gómez-Martino Arroyo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital San Pedro de Alcántara, Complejo Hospitalario de Cáceres, Cáceres, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reacción a membranas sintéticas en hemodiálisis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although the incidence of hypersensitivity reactions in haemodialysis (HD) is low and their severity varies, these reactions are not rare and can be lethal.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Recently several cases associated with the use of synthetic membranes have been reported.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> These reactions are either mild to moderate, with minimal clinical repercussions that go unnoticed, or severe with a wide range of symptoms which could prove lethal.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 80-year-old man with chronic kidney disease of vascular aetiology, receiving treatment with HD since January 2016.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is an ex-smoker with a personal history of hypertension, hypercholesterolaemia, hyperuricaemia, anaemia and hyperparathyroidism secondary to kidney disease, intermittent claudication, chronic obstructive pulmonary disease, depressive syndrome and treated lentigo maligna. Although the patient has no allergic history, he does have a dermatological history of sebaceous hyperplasia and lichenoid pityriasis treated with paraben- and cortisone-free moisturising lotions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On treatment with manidipine, bisoprolol, torasemide, allopurinol, ezetimibe/simvastatin, paricalcitol, calcifediol, sevelamer carbonate, salmeterol/fluticasone, amitriptyline, erythropoietin and intravenous iron sucrose.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient has a poorly developed left humeral-cephalic arteriovenous fistula, and is dialysed through a permanent right jugular catheter.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He began conventional HD due to uraemic symptoms. Ultrapure water and a gamma-sterilised polyethersulfone dialyser with high permeability (Phylther-LF21SD<span class="elsevierStyleSup">®</span>) were used. In the first HD session, the patient presented with severe bronchospasm with hypotension and desaturation at the beginning of the session. High-flow oxygen therapy, hydrocortisone and bronchodilators were prescribed: the symptoms gradually disappeared within a few minutes of administration, without interrupting the HD session.</p><p id="par0035" class="elsevierStylePara elsevierViewall">No wheezing was observed in the lung auscultation and no condensation was noticed on the chest X-ray. The electrocardiogram and laboratory tests, which included leukocyte and platelet counts, myocardial damage enzymes and acute-phase reactants, were normal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The bronchospasm symptoms reappeared in successive sessions, although they were milder and gradually disappeared with oxygen therapy. The patient's symptoms were attributed to an intercurrent episode of upper respiratory tract infection. After the first month, the HD sessions were followed by dyspnoea and bronchospasm after the session: the episodes gradually increased in severity and duration. At the beginning of each dialysis, the patient presented with desaturation, excessive sweating, tachypnoea and blood pressure >200/100<span class="elsevierStyleHsp" style=""></span>mmHg; before the session, blood pressure was 130/80<span class="elsevierStyleHsp" style=""></span>mmHg. Premedication was prescribed with hydrocortisone, intravenous methylprednisolone, antihistamines and inhaled bronchodilators, with the patient being asymptomatic and normotensive at the end of the sessions.</p><p id="par0045" class="elsevierStylePara elsevierViewall">On suspecting an adverse reaction to the dialyser, we switched to steam-sterilised polysulfone and PVP membranes (Helixona-FX80<span class="elsevierStyleSup">®</span>), but the patient presented with the same symptoms. We then changed the anticoagulation regimen, suspended iron therapy, and prepared the patient by administering abundant serum, but the episodes continued. No eosinophilia, increased IgE or anti-heparin antibodies were observed, while cultures of the dialysis fluid and endotoxins were negative. The material used was free of ethylene oxide and latex. There were no other cases in the unit.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We finally decided to replace the synthetic membranes with a cellulose triacetate dialyser (Sureflux<span class="elsevierStyleSup">®</span>-21L, Nipro). Since then the patient has not experienced any similar events.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The case reported falls within the type A anaphylactic hypersensitivity reactions (not measured by IgE), because of the time of onset, i.e. within the first few minutes of HD after the blood had come into contact with the components of the extracorporeal circuit, and the type of symptoms.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Other causes of anaphylactic reaction such as endotoxin retro-filtration,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> hypersensitivity to iron,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> anti-heparin antibodies,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> sterilisation methods<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> or use of angiotensin-converting enzyme inhibitors<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> were ruled out. The reaction was attributed to the blood coming into contact with synthetic materials.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Interestingly, although the patient initially presented with a classic triad with severe symptoms, in successive sessions the symptoms were mild and went unnoticed. Although the reaction was subsequently repeated with greater severity and duration in each dialysis, with a potential increase in severity, the symptoms disappeared in all cases after the first 90–120<span class="elsevierStyleHsp" style=""></span>min of each session, without interrupting the dialysis treatment.</p><p id="par0065" class="elsevierStylePara elsevierViewall">As in other published cases, respiratory symptoms were the most common, with all symptoms disappearing after substituting the synthetic dialyser with a cellulose triacetate one.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,10</span></a> This material causes fewer hypersensitivity reactions, probably due to a lower activation of the platelet membrane receptor (GpIIb/IIIa), with less alteration of the aggregation, although the mechanisms involved are still unclear.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">We report our experience with a case of hypersensitivity to synthetic dialysers with a peculiar clinical course, which included episodes of different severity, which is why it went unnoticed. Because of the potential life-threatening risk involved in this type of reaction, we emphasise the importance of suspecting them when the clinical symptoms or course are unusual.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no potential conflicts of interest related to the content of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Sanchidrián S, Labrador Gómez PJ, Marín Álvarez JP, Jiménez Herrero MC, Castellano Cerviño I, Gallego Domínguez S, et al. Reacción a membranas sintéticas en hemodiálisis. Nefrologia. 2016;36:707–709.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reacciones de hipersensibilidad en hemodiálisis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.A. Álvarez-Lara" 1 => "A. Martín-Malo" 2 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 41 | 33 | 74 |
| 2024 September | 39 | 25 | 64 |
| 2024 August | 68 | 48 | 116 |
| 2024 July | 31 | 23 | 54 |
| 2024 June | 45 | 33 | 78 |
| 2024 May | 45 | 29 | 74 |
| 2024 April | 47 | 33 | 80 |
| 2024 March | 34 | 25 | 59 |
| 2024 February | 31 | 35 | 66 |
| 2024 January | 17 | 28 | 45 |
| 2023 December | 23 | 18 | 41 |
| 2023 November | 25 | 30 | 55 |
| 2023 October | 40 | 33 | 73 |
| 2023 September | 29 | 25 | 54 |
| 2023 August | 23 | 29 | 52 |
| 2023 July | 45 | 36 | 81 |
| 2023 June | 69 | 27 | 96 |
| 2023 May | 56 | 28 | 84 |
| 2023 April | 48 | 13 | 61 |
| 2023 March | 70 | 25 | 95 |
| 2023 February | 40 | 24 | 64 |
| 2023 January | 29 | 21 | 50 |
| 2022 December | 56 | 30 | 86 |
| 2022 November | 53 | 31 | 84 |
| 2022 October | 46 | 38 | 84 |
| 2022 September | 31 | 31 | 62 |
| 2022 August | 41 | 38 | 79 |
| 2022 July | 30 | 44 | 74 |
| 2022 June | 34 | 27 | 61 |
| 2022 May | 37 | 30 | 67 |
| 2022 April | 34 | 44 | 78 |
| 2022 March | 54 | 38 | 92 |
| 2022 February | 26 | 40 | 66 |
| 2022 January | 39 | 28 | 67 |
| 2021 December | 32 | 38 | 70 |
| 2021 November | 39 | 33 | 72 |
| 2021 October | 40 | 39 | 79 |
| 2021 September | 32 | 33 | 65 |
| 2021 August | 37 | 44 | 81 |
| 2021 July | 33 | 28 | 61 |
| 2021 June | 36 | 37 | 73 |
| 2021 May | 45 | 48 | 93 |
| 2021 April | 286 | 51 | 337 |
| 2021 March | 58 | 45 | 103 |
| 2021 February | 61 | 21 | 82 |
| 2021 January | 50 | 26 | 76 |
| 2020 December | 35 | 16 | 51 |
| 2020 November | 46 | 15 | 61 |
| 2020 October | 30 | 36 | 66 |
| 2020 September | 37 | 15 | 52 |
| 2020 August | 44 | 12 | 56 |
| 2020 July | 43 | 16 | 59 |
| 2020 June | 35 | 14 | 49 |
| 2020 May | 66 | 19 | 85 |
| 2020 April | 41 | 29 | 70 |
| 2020 March | 32 | 10 | 42 |
| 2020 February | 38 | 24 | 62 |
| 2020 January | 44 | 24 | 68 |
| 2019 December | 43 | 22 | 65 |
| 2019 November | 53 | 32 | 85 |
| 2019 October | 36 | 17 | 53 |
| 2019 September | 32 | 11 | 43 |
| 2019 August | 29 | 33 | 62 |
| 2019 July | 30 | 26 | 56 |
| 2019 June | 36 | 33 | 69 |
| 2019 May | 30 | 34 | 64 |
| 2019 April | 57 | 48 | 105 |
| 2019 March | 53 | 22 | 75 |
| 2019 February | 24 | 18 | 42 |
| 2019 January | 33 | 20 | 53 |
| 2018 December | 125 | 35 | 160 |
| 2018 November | 258 | 26 | 284 |
| 2018 October | 180 | 25 | 205 |
| 2018 September | 83 | 12 | 95 |
| 2018 August | 48 | 22 | 70 |
| 2018 July | 62 | 18 | 80 |
| 2018 June | 56 | 12 | 68 |
| 2018 May | 86 | 16 | 102 |
| 2018 April | 110 | 10 | 120 |
| 2018 March | 100 | 7 | 107 |
| 2018 February | 136 | 6 | 142 |
| 2018 January | 151 | 8 | 159 |
| 2017 December | 101 | 6 | 107 |
| 2017 November | 59 | 17 | 76 |
| 2017 October | 51 | 7 | 58 |
| 2017 September | 66 | 29 | 95 |
| 2017 August | 78 | 27 | 105 |
| 2017 July | 96 | 26 | 122 |
| 2017 June | 67 | 38 | 105 |
| 2017 May | 66 | 33 | 99 |
| 2017 April | 81 | 34 | 115 |
| 2017 March | 65 | 46 | 111 |
| 2017 February | 41 | 9 | 50 |
| 2017 January | 40 | 13 | 53 |
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