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and even polysulfone-polyvinylpyrrolidone&#44; a compound used to prevent possible adverse reactions produced by the interaction of the polysulfone membrane with platelets and plasma proteins&#44; have also been reported<span class="elsevierStyleSup">5-7</span>&#46;</p><p class="elsevierStylePara">In this article we would like to describe 6 cases of adverse reactions to synthetic HD membranes in our department since 2011&#44; with particular intensity between May and July 2013&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CLINICAL CASES</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 1</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 58-year-old male patient&#44; positive for hepatitis C virus &#40;HCV&#41;&#44; with chronic renal failure &#40;CRF&#41; secondary to adult hepatorenal polycystic disease&#44; on the HD programme from 1996 to 2000&#44; the year in which he received a cadaveric-donor kidney transplant&#46; Functioning transplant until May 2010&#44; when he restarted HD due to stage 4-5T chronic allograft dysfunction secondary to chronic humoral rejection in the biopsy&#46; The patient usually received high-flux polysulfone dialyser by predilution online &#40;Helixone<span class="elsevierStyleSup">&#174;</span> FX-800&#44; FMC&#41;&#46; He had no known history of allergies&#46; In July 2011&#44; due to supply problems&#44; the dialyser was changed to high-flux polyamide &#40;Polyflux<span class="elsevierStyleSup">&#174;</span> 210H&#44; Gambro&#41;&#46; After being connected for 20 minutes&#44; we noted oppressive chest pain accompanied by hypotension &#40;blood pressure &#91;BP&#93; 80&#47;40&#160;mmHg&#41; and 88&#37; desaturation&#46; Pulmonary auscultation did not reveal wheezing&#46; After returning the circuit and prescribing high-flow oxygen&#44; the patient improved spontaneously&#46; After stabilising the vital signs &#40;BP 130&#47;70 and 94&#37; baseline oxygen saturation&#41;&#44; the session was restarted and ultrafiltration reduced&#44; without further complications&#46;</p><p class="elsevierStylePara">In the following HD session&#44; after being connected for 20 minutes&#44; he presented the same symptoms as in the previous session &#40;chest pain with hypotension and 78&#37; oxygen saturation&#41;&#46; The patient was returned to and prescribed high flow oxygen and 1g intravenous &#40;IV&#41; paracetamol&#46; He improved noticeably following this treatment and consequently the HD session was restarted&#44; finishing without complications&#46;</p><p class="elsevierStylePara">Given a suspicion of adverse reaction to the dialyser&#44; we decided to change it in the following session to a polynephron membrane &#40;Elisio<span class="elsevierStyleSup">TM</span>-21H&#44; Nipro&#41;&#46; When he had been connected for 35 minutes&#44; he experienced central chest pain&#44; holocranial headache and abdominal pain&#46; Pulmonary auscultation did not reveal wheezing&#46; BP was 80&#47;50mmHG&#44; for which reason we returned to the patient&#46; High doses of oxygen and 1g IV paracetamol were prescribed&#44; with which the patient improved and 30 minutes after presenting symptoms&#44; the HD session was restarted&#44; which was completed without complications&#46;</p><p class="elsevierStylePara">Complementary tests &#40;troponin I and electrocardiogram &#91;ECG&#93;&#41; found no significant differences with respect to earlier tests&#46; The analysis of the third session only showed leucopoenia &#40;2&#44;300 leukocytes&#47;ml&#41; with normal formula&#44; the same magnitude of thrombocytopenia as previously &#40;54&#44;000 platelets&#47;ml&#41;&#44; slightly elevated C-reactive protein &#40;CRP&#41; &#40;11&#46;5mg&#47;l&#41; and increase of D-dimer &#40;8&#44;544ng&#47;ml&#59; 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an hour and a half into dialysis&#44; she experienced sweating&#44; tachypnoea and dyspnoea&#59; 78&#37; oxygen saturation was observed&#44; overcome using high-flow oxygen&#46; Maintained BP&#46; Pulmonary auscultation did not reveal wheezing&#46; Analysis showed mild leukocytosis &#40;12&#44;500 leukocytes with normal formula&#41;&#44; normal troponin I with CRP 8mg&#47;l&#44; with no other noteworthy findings&#46; ECG was similar to previous tests&#46; 20 minutes after presenting symptoms&#44; spontaneous improvement of the patient was observed&#44; finishing HD without complications&#46; Post-HD thoracic radiography was performed&#44; which did not show consolidations&#44; effusion or vascular redistribution&#59; it only showed the known increased cardiothoracic index&#46;</p><p class="elsevierStylePara">After this incident&#44; HD sessions ran without problems for a month&#44; until 17 October 2012&#44; when the patient experienced sweating and significant dyspnoea during HD&#44; 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we decided to change the filter to Poliflux<span class="elsevierStyleSup">&#174;</span> 210H for the next HD session&#46; Subsequent sessions ran without complications&#46; On 24 October 2012 &#40;third session with Poliflux&#41;&#44; 1h from finishing HD&#44; she experienced general discomfort&#44; sweating&#44; dyspnoea and hypotension &#40;87&#47;36mmHg&#41;&#46; Pulmonary auscultation did not reveal wheezing&#46; 200mg of hydrocortisone was administered&#44; with complete disappearance of the symptoms&#46; The filter was changed again to Elisio<span class="elsevierStyleSup">TM</span>-21H for subsequent HD sessions&#44; which ran without complications&#46; On 7 June 2013&#44; eight months later&#44; the patient presented dyspnoea and non-irradiated&#44; oppressive central chest pain 30 minutes into dialysis&#46; BP&#58; 210&#47;75mmHg&#46; 90&#37; oxygen saturation with oxigen nasal cannula&#46; Physical examination revealed general hypoventilation&#44; with wheezing in all lung fields&#46; Despite administering 300mg of hydrocortisone&#44; the patient persisted with general wheezing&#59; therefore we decided to stop HD and disconnect the whole system&#46; An additional 200mg of hydrocortisone&#44; 40mg of IV methylprednisolone and ipratropium bromide inhalation were administered&#46; The patient&#8217;s clinical symptoms improved progressively&#44; with respiratory symptoms disappearing&#46; For this reason we decided to continue the HD session using SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#59; the patient remained asymptomatic&#46; Only CRP 21&#46;6mg&#47;l and haemoglobin 8&#46;6g&#47;dl stood out in the analysis&#44; for which reason 2 red blood cell concentrates were transfused&#46; ECG did not show changes from previous tests&#46;</p><p class="elsevierStylePara">SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX dialyser was kept for subsequent HD sessions&#44; with no complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 75-year-old male with stage 4 CRF&#44; admitted to cardiology due to complete auricular-ventricular block requiring implantation of a pacemaker&#44; along with symptoms of decompensated heart failure and secondary reduced renal function&#46; The patient had no known history of allergies&#46;</p><p class="elsevierStylePara">On 28 May 2013&#44; we opted for the patient&#8217;s acute HD treatment&#46; Conventional HD using Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix was prescribed&#46; 15 minutes into the session&#44; the patient suddenly experienced dyspnoea&#44; 72&#37; oxygen saturation and clinical signs of severe bronchospasm&#46; The blood pump was stopped and 300mg of hydrocortisone and high-flow oxygen were administered&#46; We decided to interrupt the HD session and&#44; given the suspicion of adverse reaction to the dialyser&#44; the blood was removed from the circuit&#46; After 15 minutes the patient was asymptomatic&#46; HD was not required until 16 June 2013&#44; when a session was carried out using FX-100&#46; After 15 minutes the patient experienced the same symptoms as previously and oxygen saturation reduced to 80&#37;&#46; The blood pump was stopped and 300mg of hydrocortisone&#44; 40mg of methylpredisolone and high-flow oxygen were administered&#46; It was decided not to return the circuit&#8217;s blood&#44; changing the dialyser to SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#46; The patient slowly started to improve until symptoms completely disappeared&#44; finishing the session with the new dialyser&#44; and with no further complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 4</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 48-year-old male&#44; positive for human immunodeficiency virus and HCV&#44; diagnosed with CRF of multifactorial origin&#44; with no known history of allergies&#44; who had stopped follow-up consultations and was admitted due to worsening renal function &#40;Cr 15mg&#47;dl&#41;&#44; secondary to chronic diarrhoea of 6 months progression and sustained hypotension &#40;70&#47;40mmHg&#41;&#46; During admission&#44; the right jugular vein was channelled and one HD session was carried out on 16 July 2013&#46; The Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix dialyser was used&#46; Two hours into treatment he experienced sudden dyspnoea&#44; with 78&#37;-80&#37; oxygen saturation&#44; presenting general hypoventilation with bibasal crackles and wheezing in both hemithorax in pulmonary auscultation&#46; We decided to interrupt treatment and not return the system&#46; Saturation rose to 98&#37; following administration of high-flow oxygen and 100mg IV hydrocortisone&#44; with pulmonary auscultation without pathological sounds and improvement of respiratory dynamic&#46; The patient was transferred from the department&#44; for which reason we lost the follow-up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 5</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 70-year-old male&#44; solitary right kidney&#44; with history of stage 5 CRF secondary to nephrosclerosis&#44; with no known allergies&#44; was admitted in June 2013 as scheduled for myocardial revascularisation due to chronic ischaemic heart disease expressed as lesion of the left coronary trunk and three vessels&#46; During admission he presented multiple post-operative complications&#44; requiring continuous techniques of kidney replacement therapy during his stay in the resuscitation unit using a polysulfone dialyser &#40;Aquamax<span class="elsevierStyleSup">&#174;</span> HF-12&#44; Baxter&#41;&#46; After his transfer to the medical ward&#44; periodic HD sessions with Helixone<span class="elsevierStyleSup">&#174;</span> FX 100 Classix were prescribed&#46; 20 minutes into the first session&#44; the patient experienced hypotension &#40;80&#47;40mmHg&#41;&#44; dyspnoea and bronchospasm symptoms&#46; After stopping the blood pump and returning the system&#44; 200mg of hydrocortisone and high-flow oxygen were administered&#59; the patient improved progressively&#46; 20 minutes into the next HD session using the same filter&#44; the clinical symptoms repeated&#46; For this reason we decided to carry out subsequent HD sessions using cellulose triacetate &#40;SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#41;&#44; with no complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 6</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">An 83-year-old female patient&#44; diagnosed with stage 5 CRF secondary to chronic pyelonephritis&#44; admitted due to worsening renal function in the context of diarrhoea&#46;&#160; The patient had no known history of allergies&#46; Given the lack of improvement of the renal function&#44; we decided to begin HD on 11 July 2013 using Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix&#46; After 30 minutes of conventional HD&#44; the patient presented symptoms of arterial hypotension&#44; dyspnoea and 60-80&#37; oxygen desaturation&#44; accompanied by poor peripheral perfusion&#46; High doses of oxygen and fluid therapy were administered&#44; with improvement of BP&#44; but not the clinical situation&#59; therefore we decided to stop the HD session&#46; After suspending dialysis&#44; saturation returned to baseline values and the patient improved clinically&#46; In subsequent sessions&#44; the filter was replaced by SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#44; with no new complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">We present a six-case series of mostly early-stage hypersensitivity reactions to an HD session&#44; characterised by general malaise&#44; desaturation&#44; bronchospasm when determined&#44; and arterial hypotension&#46; There was good response to the session&#8217;s temporary suspension and reappearance of reactions in subsequent sessions which used a synthetic dialyser&#46; No hypersensitivity reactions reappeared in successive observations of sessions using a cellulose membrane&#46; No patients had a history of allergies and no causal relationship with the administered medication was found&#46;</p><p class="elsevierStylePara">As a peculiarity in the first two cases&#44; there was the apparent saturation of the hypersensitivity mechanism for the dialyser that caused the reaction&#59; that is&#44; the reaction only occurred in the first moments and it was possible to resume HD using the previous dialyser&#44; without complications&#46; The remaining cases showed greater reaction severity and there was no other choice but suspension of HD&#46; These cases were a learning curve for professionals in recognising the situation&#46; The genesis of apparent universal hypersensitivity to synthetic membranes was also common among those patients in which a different membrane from the same group was tried&#46; This procedure was not performed in some patients given the severity of their previous symptoms&#46; After presenting symptoms&#44; all patients were submitted to one or several HD sessions using a cellulose dialyser with no similar complications&#44; centring the hypersensitivity process on the dialyser&#46;</p><p class="elsevierStylePara">The hospital&#8217;s allergologists admitted&#44; after evaluating the cases&#44; that they could be classified as serious hypersensitivity reactions to the polysulfone dialyser&#46;</p><p class="elsevierStylePara">We also attributed a certain epidemic character to the entire episode&#44; due to the study being concentrated in two years&#44; July 2011-July 2013&#44; especially between May and July 2013&#46; After this date&#44; despite using the membrane in 90&#160;&#37; of our population&#44; there was no reoccurrence of a similar case&#46; The cases were notified to the Spanish Agency of Medicines as adverse reactions and they informed us that they had not received any similar correspondence&#46; There are still yet to be further notifications on this matter&#46;</p><p class="elsevierStylePara">Traditionally hypersensitivity reactions to a dialyser have been considered as rare events &#40;4 out of every 100&#44;000 sessions&#41;&#59; however&#44; at the end of the 1980s&#44; Nicholls et al&#46; carried out a study in the United Kingdom and highlighted that the problem could be of greater significance<span class="elsevierStyleSup">8</span>&#46; Type A hypersensitivity reactions regularly occurred in the first minutes of the HD session after blood came into contact with components of the extracorporeal circuit&#46; These processes are mediated by preformed antibodies and&#44; in the most serious cases&#44; can cause dyspnoea&#44; hypertension&#44; unconsciousness&#44; cardiac arrest and death&#46; Given the suspicion of this adverse reaction&#44; immediate action consists of stopping the blood pump&#44; disconnecting the entire extracorporeal circuit&#44; and administering high-flow oxygen&#44; as well as short-acting antihistamines and corticosteroids&#44; hydrocortisone and starting assisted respiration where necessary&#46; Type B hypersensitivity reactions&#44; much less frequent&#44; usually occur after the first 30 minutes of the HD session&#46; Clinical signs are less specific&#44; such as chest and back pain&#44; and do not require the HD session to be interrupted&#46;</p><p class="elsevierStylePara">Bigazzi et al&#46; described how&#44; in the presence of contaminated fluid and through high-flux membranes&#44; there could be back-filtration of pyrogens into the blood compartment&#46; This causes hypersensitivity reactions at the start of the session in patients dialysed using these membrane types<span class="elsevierStyleSup">9</span>&#46; In the case of our patients&#44; all were dialysed using highly permeable membranes and ultrapure water in accordance with European Pharmacopoeia standards<span class="elsevierStyleSup">10</span>&#46; Complying with these regulations&#44; with periodic monthly checks&#44; and the absence of reactions in sessions immediately performed using another highly permeable&#44; non-synthetic dialyser&#44; make it very unlikely that it is the triggering mechanism of a hypersensitivity reaction&#46;</p><p class="elsevierStylePara">The majority of adverse reactions occurred between May and July 2013 in the patients&#8217; first HD session using modified polysulfone dialysers&#46; Cases of severe reactions to polysulfone have been described<span class="elsevierStyleSup">5&#44;6</span>&#44; as well as hypersensitivity crossed to other types of membrane such as polycarbonate and polymethyl methylcrylate<span class="elsevierStyleSup">11</span>&#46; These reactions to polysulfone could be different depending on its manufacturer&#46; Therefore&#44; HD sessions using other synthetic dialysers were attempted in cases 1 and 2 without success&#46;</p><p class="elsevierStylePara">Another point of interest is the different sterilisation method of the dialysers&#46; M&#252;ller et al&#46; reported that vapour-sterilisation could increase the dialyser&#8217;s biocompatibility in comparison to sterilisation using ethylene oxide<span class="elsevierStyleSup">12</span>&#46; Golli-Bennour et al&#46; affirmed that the membranes sterilised using vapour increased the viability of the endothelial cells compared to sterilisation methods using radiation or ethylene oxide<span class="elsevierStyleSup">13</span>&#46; In addition&#44; they showed that&#44; according to the sterilisation method&#44; the concentration of serum malondialdehyde&#44; used as a maker for lipid peroxidation&#44; increased substantially with respect to healthy patients when the dialyser&#8217;s sterilisation was by gamma radiation or ethylene oxide&#46; However&#44; other authors have reported that vapour sterilisation does not seem to have an effect on the freeing of pro-inflammatory cytokines&#44; such as interleukin-1&#46; In our patients&#44; membrane sterilisation was heterogeneous&#59; FX and Poliflux dialysers are sterilised using vapour&#44; while cellulose triacetate and Eliseo dialysers are sterilised using gamma rays&#44; making it difficult to establish a causal relationship&#46;</p><p class="elsevierStylePara">A key finding in the cases in our department is that all hypersensitivity reactions disappeared after changing the dialyser to cellulose triacetate&#46; Urbani et al&#46; showed differences between the helixone and cellulose triacetate dialysers when they were studied through proteomics<span class="elsevierStyleSup">14</span>&#46; Abundant proteins involved in the blood-dialyser interaction were found on the helixone membrane&#44; such as ficolin-2 and fibrinogen fragments&#46; Other authors had already demonstrated the absorption of ficolin-2 in polisulfone dialysers&#44; which could contribute to the complement&#8217;s activation&#44; leukocyte adhesion and&#44; at worst&#44; blood coagulation<span class="elsevierStyleSup">15&#44;16</span>&#46; In addition&#44; it was published that cellulose triacetate induces less hypersensitivity reactions&#44; probably due to less activation of the platelet membrane &#40;GpIIb&#47;IIIa&#41;&#44; producing less aggregation disease<span class="elsevierStyleSup">17</span>&#46; The mechanisms making our patients sensitive to the described synthetic dialysers and not to the cellulose triacetate dialyser are not clear&#46; Therefore we are designing specific <span class="elsevierStyleItalic">ex vivo </span>response studies on immunocompetent cells for those patients who showed allergic reaction to synthetic dialysers&#44; as well as cross-sectional response studies on hypersensitivity with various HD membranes&#46;</p><p class="elsevierStylePara">Adverse reactions to dialysers are a severe complication intrinsic to the therapy itself&#46; The nephrologists should be alert to this possibility&#44; acting immediately faced with mere clinical suspicion and referring the patient to the allergy department to complete the study as soon as possible&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">The authors thank Dr&#46; Rafael P&#233;rez Garc&#237;a for his revision and correction of this article&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">La realizaci&#243;n de una sesi&#243;n de hemodi&#225;lisis &#40;HD&#41; supone un cierto riesgo de aparici&#243;n de reacciones adversas de hipersensibilidad&#44; al estar en contacto abundantes cantidades de sangre con diferentes materiales de origen sint&#233;tico&#46; En HD han sido descritas reacciones de hipersensibilidad al &#243;xido de etileno y a membranas no biocompatibles como el cuproamonio&#46; Tambi&#233;n se han comunicado casos de hipersensibilidad con membranas biocompatibles como la polisulfona&#44; e incluso con polisulfona asociada a polivinilpirrolidona&#46; En este art&#237;culo queremos describir seis casos acontecidos en nuestro servicio de reacciones de hipersensibilidad mayoritariamente temprana a la sesi&#243;n de HD&#44; caracterizados por mal estado general&#44; desaturaci&#243;n&#44; broncoespasmo e hipotensi&#243;n arterial&#44; con buena respuesta a la suspensi&#243;n temporal de la sesi&#243;n y con reaparici&#243;n en sesiones posteriores siempre que se utilizase un dializador sint&#233;tico&#46; Todas tienen en com&#250;n no haberse dado de nuevo en sucesivas observaciones cuando las sesiones fueron realizadas con una membrana de celulosa&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Undergoing a haemodialysis &#40;HD&#41; session poses a certain risk of hypersensitivity adverse reactions as large quantities of blood are in contact with various synthetic materials&#46; Hypersensitivity reactions to ethylene oxide and non-biocompatible membranes&#44; such as cuprophane&#44; have been described in HD&#46; Cases of hypersensitivity with biocompatible membranes&#44; such as polysulfone&#44; and even polysulfone-polyvinylpyrrolidone&#44; have also been reported&#46; In this article we describe six cases of mostly early-stage hypersensitivity reactions to HD occurring in our department&#44; characterised by malaise&#44; desaturation&#44; bronchospasm and arterial hypotension&#44; with good response to the session&#8217;s temporary suspension and with reappearance in subsequent sessions that used a synthetic dialyser&#46; No hypersensitivity reactions reappeared in successive observations when the sessions were carried out using a cellulose membrane&#46;</p>"
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                  "referenciaCompleta" => "Lemke HD, Heidland A, Schaefer RM. Hypersensitivity reactions during haemodialysis: role of complement fragments and ethylene oxide antibodies. Nephrol Dial Transplant 1990;5:264-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2113222" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Bommer J, Ritz E. Ethylene oxide (ETO) as a major cause of anaphylactoid reactions in dialysis (a review). Artif Organs 1987;11:111-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2954522" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Ohashi N, Yonemura K, Goto T, Suzuki H, Fujigaki Y, Yamamoto T, et al. A case of anaphylactoid shock induced by the BS polysulfone hemodialyzer but not by the F8-HPS polysulfone hemodialyzer. Clin Nephrol 2003;60:214-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14524587" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Bacelar Marques ID, Pinheiro KF, de Freitas do Carmo LP, Costa MC, Abensur H. Anaphylactic reaction induced by a polysulfone/polyvinylpyrrolidone membrane in the 10th session of hemodialysis with the same dialyzer. Hemodial Int 2011;15:399-403. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21624039" target="_blank">[Pubmed]</a>"
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Hypersensitivity reactions to synthetic haemodialysis membranes
Reacciones de hipersensibilidad a membranas sintéticas de hemodiálisis
Rafael J. Sánchez-Villanuevaa, Elena Gonzáleza, Santiago Quirceb, Raquel Díaza, Laura Álvareza, David Menéndeza, Lucía Rodríguez-Gayoa, M. Auxiliadora Bajoa, Rafael Selgasa
a Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain,
b Servicio de Alergología, Hospital Universitario La Paz, Madrid, Spain,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Undergoing a haemodialysis &#40;HD&#41; session poses a certain risk of hypersensitivity adverse reactions as large quantities of blood are in contact with various synthetic materials&#46; These hypersensitivity reactions associated with the HD technique have been traditionally categorised into two types&#58; type A or hypersensitivity reactions&#44; which tend to occur immediately&#44; and type B or non-specific reactions&#44; which tend to start later<span class="elsevierStyleSup">1</span>&#46;</p><p class="elsevierStylePara">Hypersensitivity reactions to ethylene oxide and non-biocompatible membranes&#44; such as cuprophane&#44; have been described in HD<span class="elsevierStyleSup">2-4</span>&#46; Cases of hypersensitivity with biocompatible membranes&#44; such as polysulfone&#44; and even polysulfone-polyvinylpyrrolidone&#44; a compound used to prevent possible adverse reactions produced by the interaction of the polysulfone membrane with platelets and plasma proteins&#44; have also been reported<span class="elsevierStyleSup">5-7</span>&#46;</p><p class="elsevierStylePara">In this article we would like to describe 6 cases of adverse reactions to synthetic HD membranes in our department since 2011&#44; with particular intensity between May and July 2013&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CLINICAL CASES</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 1</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 58-year-old male patient&#44; positive for hepatitis C virus &#40;HCV&#41;&#44; with chronic renal failure &#40;CRF&#41; secondary to adult hepatorenal polycystic disease&#44; on the HD programme from 1996 to 2000&#44; the year in which he received a cadaveric-donor kidney transplant&#46; Functioning transplant until May 2010&#44; when he restarted HD due to stage 4-5T chronic allograft dysfunction secondary to chronic humoral rejection in the biopsy&#46; The patient usually received high-flux polysulfone dialyser by predilution online &#40;Helixone<span class="elsevierStyleSup">&#174;</span> FX-800&#44; FMC&#41;&#46; He had no known history of allergies&#46; In July 2011&#44; due to supply problems&#44; the dialyser was changed to high-flux polyamide &#40;Polyflux<span class="elsevierStyleSup">&#174;</span> 210H&#44; Gambro&#41;&#46; After being connected for 20 minutes&#44; we noted oppressive chest pain accompanied by hypotension &#40;blood pressure &#91;BP&#93; 80&#47;40&#160;mmHg&#41; and 88&#37; desaturation&#46; Pulmonary auscultation did not reveal wheezing&#46; After returning the circuit and prescribing high-flow oxygen&#44; the patient improved spontaneously&#46; After stabilising the vital signs &#40;BP 130&#47;70 and 94&#37; baseline oxygen saturation&#41;&#44; the session was restarted and ultrafiltration reduced&#44; without further complications&#46;</p><p class="elsevierStylePara">In the following HD session&#44; after being connected for 20 minutes&#44; he presented the same symptoms as in the previous session &#40;chest pain with hypotension and 78&#37; oxygen saturation&#41;&#46; The patient was returned to and prescribed high flow oxygen and 1g intravenous &#40;IV&#41; paracetamol&#46; He improved noticeably following this treatment and consequently the HD session was restarted&#44; finishing without complications&#46;</p><p class="elsevierStylePara">Given a suspicion of adverse reaction to the dialyser&#44; we decided to change it in the following session to a polynephron membrane &#40;Elisio<span class="elsevierStyleSup">TM</span>-21H&#44; Nipro&#41;&#46; When he had been connected for 35 minutes&#44; he experienced central chest pain&#44; holocranial headache and abdominal pain&#46; Pulmonary auscultation did not reveal wheezing&#46; BP was 80&#47;50mmHG&#44; for which reason we returned to the patient&#46; High doses of oxygen and 1g IV paracetamol were prescribed&#44; with which the patient improved and 30 minutes after presenting symptoms&#44; the HD session was restarted&#44; which was completed without complications&#46;</p><p class="elsevierStylePara">Complementary tests &#40;troponin I and electrocardiogram &#91;ECG&#93;&#41; found no significant differences with respect to earlier tests&#46; The analysis of the third session only showed leucopoenia &#40;2&#44;300 leukocytes&#47;ml&#41; with normal formula&#44; the same magnitude of thrombocytopenia as previously &#40;54&#44;000 platelets&#47;ml&#41;&#44; slightly elevated C-reactive protein &#40;CRP&#41; &#40;11&#46;5mg&#47;l&#41; and increase of D-dimer &#40;8&#44;544ng&#47;ml&#59; 2&#44;117ng&#47;ml in June 2011&#41;&#46; Therefore&#44; a computed tomography angiogram of the pulmonary arteries was requested&#44; which showed pulmonary thromboembolism&#46;</p><p class="elsevierStylePara">Given a suspicion of possible allergy to synthetic membranes&#44; we decided to perform the next HD session using cellulose triacetate &#40;SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#44; Nipro&#41;&#46; The patient did not present symptoms in either this session or in any subsequent session to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 2</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">An 80-year-old female with CRF of multifactorial aetiology&#44; on HD since May 2012&#46; The patient had no known history of allergies&#46; She regularly underwent HD using Helixone<span class="elsevierStyleSup">&#174;</span> FX-80 from the start&#46;</p><p class="elsevierStylePara">On 14 September 2012&#44; an hour and a half into dialysis&#44; she experienced sweating&#44; tachypnoea and dyspnoea&#59; 78&#37; oxygen saturation was observed&#44; overcome using high-flow oxygen&#46; Maintained BP&#46; Pulmonary auscultation did not reveal wheezing&#46; Analysis showed mild leukocytosis &#40;12&#44;500 leukocytes with normal formula&#41;&#44; normal troponin I with CRP 8mg&#47;l&#44; with no other noteworthy findings&#46; ECG was similar to previous tests&#46; 20 minutes after presenting symptoms&#44; spontaneous improvement of the patient was observed&#44; finishing HD without complications&#46; Post-HD thoracic radiography was performed&#44; which did not show consolidations&#44; effusion or vascular redistribution&#59; it only showed the known increased cardiothoracic index&#46;</p><p class="elsevierStylePara">After this incident&#44; HD sessions ran without problems for a month&#44; until 17 October 2012&#44; when the patient experienced sweating and significant dyspnoea during HD&#44; with 76&#37; oxygen saturation&#46; Pulmonary auscultation did not reveal wheezing&#46; The patient was administered oxygen at 5bpm&#44; 200mg of IV hydrocortisone and 2 salbutamol inhalations 15 minutes apart&#46; BP&#58; 115&#47;55mmHg&#46; ECG was performed with sinus rhythm 98bpm&#44; with no changes from the previous ECG&#46; Analysis showed 19&#44;000&#160;leukocytes&#47;ml&#44; 75&#37; neutrophils &#40;remainder of normal formula&#41;&#44; CRP 18mg&#47;l&#44; negative troponin I&#44; with no further alterations&#46; On re-examining the patient&#44; we examined the pruritus that had appeared on the lower limbs since the start of the session&#46; Saturation improved to 98&#37;&#44; but the patient subsequently presented hypotension of 65&#47;31mmHg&#44; for which reason the circuit was returned and the session suspended&#46; She was transferred to the Emergency department for observation&#44; being discharged without symptoms the next day&#46;</p><p class="elsevierStylePara">Given the patient&#8217;s symptoms&#44; we decided to change the filter to Poliflux<span class="elsevierStyleSup">&#174;</span> 210H for the next HD session&#46; Subsequent sessions ran without complications&#46; On 24 October 2012 &#40;third session with Poliflux&#41;&#44; 1h from finishing HD&#44; she experienced general discomfort&#44; sweating&#44; dyspnoea and hypotension &#40;87&#47;36mmHg&#41;&#46; Pulmonary auscultation did not reveal wheezing&#46; 200mg of hydrocortisone was administered&#44; with complete disappearance of the symptoms&#46; The filter was changed again to Elisio<span class="elsevierStyleSup">TM</span>-21H for subsequent HD sessions&#44; which ran without complications&#46; On 7 June 2013&#44; eight months later&#44; the patient presented dyspnoea and non-irradiated&#44; oppressive central chest pain 30 minutes into dialysis&#46; BP&#58; 210&#47;75mmHg&#46; 90&#37; oxygen saturation with oxigen nasal cannula&#46; Physical examination revealed general hypoventilation&#44; with wheezing in all lung fields&#46; Despite administering 300mg of hydrocortisone&#44; the patient persisted with general wheezing&#59; therefore we decided to stop HD and disconnect the whole system&#46; An additional 200mg of hydrocortisone&#44; 40mg of IV methylprednisolone and ipratropium bromide inhalation were administered&#46; The patient&#8217;s clinical symptoms improved progressively&#44; with respiratory symptoms disappearing&#46; For this reason we decided to continue the HD session using SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#59; the patient remained asymptomatic&#46; Only CRP 21&#46;6mg&#47;l and haemoglobin 8&#46;6g&#47;dl stood out in the analysis&#44; for which reason 2 red blood cell concentrates were transfused&#46; ECG did not show changes from previous tests&#46;</p><p class="elsevierStylePara">SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX dialyser was kept for subsequent HD sessions&#44; with no complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 75-year-old male with stage 4 CRF&#44; admitted to cardiology due to complete auricular-ventricular block requiring implantation of a pacemaker&#44; along with symptoms of decompensated heart failure and secondary reduced renal function&#46; The patient had no known history of allergies&#46;</p><p class="elsevierStylePara">On 28 May 2013&#44; we opted for the patient&#8217;s acute HD treatment&#46; Conventional HD using Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix was prescribed&#46; 15 minutes into the session&#44; the patient suddenly experienced dyspnoea&#44; 72&#37; oxygen saturation and clinical signs of severe bronchospasm&#46; The blood pump was stopped and 300mg of hydrocortisone and high-flow oxygen were administered&#46; We decided to interrupt the HD session and&#44; given the suspicion of adverse reaction to the dialyser&#44; the blood was removed from the circuit&#46; After 15 minutes the patient was asymptomatic&#46; HD was not required until 16 June 2013&#44; when a session was carried out using FX-100&#46; After 15 minutes the patient experienced the same symptoms as previously and oxygen saturation reduced to 80&#37;&#46; The blood pump was stopped and 300mg of hydrocortisone&#44; 40mg of methylpredisolone and high-flow oxygen were administered&#46; It was decided not to return the circuit&#8217;s blood&#44; changing the dialyser to SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#46; The patient slowly started to improve until symptoms completely disappeared&#44; finishing the session with the new dialyser&#44; and with no further complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 4</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 48-year-old male&#44; positive for human immunodeficiency virus and HCV&#44; diagnosed with CRF of multifactorial origin&#44; with no known history of allergies&#44; who had stopped follow-up consultations and was admitted due to worsening renal function &#40;Cr 15mg&#47;dl&#41;&#44; secondary to chronic diarrhoea of 6 months progression and sustained hypotension &#40;70&#47;40mmHg&#41;&#46; During admission&#44; the right jugular vein was channelled and one HD session was carried out on 16 July 2013&#46; The Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix dialyser was used&#46; Two hours into treatment he experienced sudden dyspnoea&#44; with 78&#37;-80&#37; oxygen saturation&#44; presenting general hypoventilation with bibasal crackles and wheezing in both hemithorax in pulmonary auscultation&#46; We decided to interrupt treatment and not return the system&#46; Saturation rose to 98&#37; following administration of high-flow oxygen and 100mg IV hydrocortisone&#44; with pulmonary auscultation without pathological sounds and improvement of respiratory dynamic&#46; The patient was transferred from the department&#44; for which reason we lost the follow-up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 5</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A 70-year-old male&#44; solitary right kidney&#44; with history of stage 5 CRF secondary to nephrosclerosis&#44; with no known allergies&#44; was admitted in June 2013 as scheduled for myocardial revascularisation due to chronic ischaemic heart disease expressed as lesion of the left coronary trunk and three vessels&#46; During admission he presented multiple post-operative complications&#44; requiring continuous techniques of kidney replacement therapy during his stay in the resuscitation unit using a polysulfone dialyser &#40;Aquamax<span class="elsevierStyleSup">&#174;</span> HF-12&#44; Baxter&#41;&#46; After his transfer to the medical ward&#44; periodic HD sessions with Helixone<span class="elsevierStyleSup">&#174;</span> FX 100 Classix were prescribed&#46; 20 minutes into the first session&#44; the patient experienced hypotension &#40;80&#47;40mmHg&#41;&#44; dyspnoea and bronchospasm symptoms&#46; After stopping the blood pump and returning the system&#44; 200mg of hydrocortisone and high-flow oxygen were administered&#59; the patient improved progressively&#46; 20 minutes into the next HD session using the same filter&#44; the clinical symptoms repeated&#46; For this reason we decided to carry out subsequent HD sessions using cellulose triacetate &#40;SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#41;&#44; with no complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 6</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">An 83-year-old female patient&#44; diagnosed with stage 5 CRF secondary to chronic pyelonephritis&#44; admitted due to worsening renal function in the context of diarrhoea&#46;&#160; The patient had no known history of allergies&#46; Given the lack of improvement of the renal function&#44; we decided to begin HD on 11 July 2013 using Helixone<span class="elsevierStyleSup">&#174;</span> FX-100 Classix&#46; After 30 minutes of conventional HD&#44; the patient presented symptoms of arterial hypotension&#44; dyspnoea and 60-80&#37; oxygen desaturation&#44; accompanied by poor peripheral perfusion&#46; High doses of oxygen and fluid therapy were administered&#44; with improvement of BP&#44; but not the clinical situation&#59; therefore we decided to stop the HD session&#46; After suspending dialysis&#44; saturation returned to baseline values and the patient improved clinically&#46; In subsequent sessions&#44; the filter was replaced by SureFlux<span class="elsevierStyleSup">&#174;</span>-21UX&#44; with no new complications to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">We present a six-case series of mostly early-stage hypersensitivity reactions to an HD session&#44; characterised by general malaise&#44; desaturation&#44; bronchospasm when determined&#44; and arterial hypotension&#46; There was good response to the session&#8217;s temporary suspension and reappearance of reactions in subsequent sessions which used a synthetic dialyser&#46; No hypersensitivity reactions reappeared in successive observations of sessions using a cellulose membrane&#46; No patients had a history of allergies and no causal relationship with the administered medication was found&#46;</p><p class="elsevierStylePara">As a peculiarity in the first two cases&#44; there was the apparent saturation of the hypersensitivity mechanism for the dialyser that caused the reaction&#59; that is&#44; the reaction only occurred in the first moments and it was possible to resume HD using the previous dialyser&#44; without complications&#46; The remaining cases showed greater reaction severity and there was no other choice but suspension of HD&#46; These cases were a learning curve for professionals in recognising the situation&#46; The genesis of apparent universal hypersensitivity to synthetic membranes was also common among those patients in which a different membrane from the same group was tried&#46; This procedure was not performed in some patients given the severity of their previous symptoms&#46; After presenting symptoms&#44; all patients were submitted to one or several HD sessions using a cellulose dialyser with no similar complications&#44; centring the hypersensitivity process on the dialyser&#46;</p><p class="elsevierStylePara">The hospital&#8217;s allergologists admitted&#44; after evaluating the cases&#44; that they could be classified as serious hypersensitivity reactions to the polysulfone dialyser&#46;</p><p class="elsevierStylePara">We also attributed a certain epidemic character to the entire episode&#44; due to the study being concentrated in two years&#44; July 2011-July 2013&#44; especially between May and July 2013&#46; After this date&#44; despite using the membrane in 90&#160;&#37; of our population&#44; there was no reoccurrence of a similar case&#46; The cases were notified to the Spanish Agency of Medicines as adverse reactions and they informed us that they had not received any similar correspondence&#46; There are still yet to be further notifications on this matter&#46;</p><p class="elsevierStylePara">Traditionally hypersensitivity reactions to a dialyser have been considered as rare events &#40;4 out of every 100&#44;000 sessions&#41;&#59; however&#44; at the end of the 1980s&#44; Nicholls et al&#46; carried out a study in the United Kingdom and highlighted that the problem could be of greater significance<span class="elsevierStyleSup">8</span>&#46; Type A hypersensitivity reactions regularly occurred in the first minutes of the HD session after blood came into contact with components of the extracorporeal circuit&#46; These processes are mediated by preformed antibodies and&#44; in the most serious cases&#44; can cause dyspnoea&#44; hypertension&#44; unconsciousness&#44; cardiac arrest and death&#46; Given the suspicion of this adverse reaction&#44; immediate action consists of stopping the blood pump&#44; disconnecting the entire extracorporeal circuit&#44; and administering high-flow oxygen&#44; as well as short-acting antihistamines and corticosteroids&#44; hydrocortisone and starting assisted respiration where necessary&#46; Type B hypersensitivity reactions&#44; much less frequent&#44; usually occur after the first 30 minutes of the HD session&#46; Clinical signs are less specific&#44; such as chest and back pain&#44; and do not require the HD session to be interrupted&#46;</p><p class="elsevierStylePara">Bigazzi et al&#46; described how&#44; in the presence of contaminated fluid and through high-flux membranes&#44; there could be back-filtration of pyrogens into the blood compartment&#46; This causes hypersensitivity reactions at the start of the session in patients dialysed using these membrane types<span class="elsevierStyleSup">9</span>&#46; In the case of our patients&#44; all were dialysed using highly permeable membranes and ultrapure water in accordance with European Pharmacopoeia standards<span class="elsevierStyleSup">10</span>&#46; Complying with these regulations&#44; with periodic monthly checks&#44; and the absence of reactions in sessions immediately performed using another highly permeable&#44; non-synthetic dialyser&#44; make it very unlikely that it is the triggering mechanism of a hypersensitivity reaction&#46;</p><p class="elsevierStylePara">The majority of adverse reactions occurred between May and July 2013 in the patients&#8217; first HD session using modified polysulfone dialysers&#46; Cases of severe reactions to polysulfone have been described<span class="elsevierStyleSup">5&#44;6</span>&#44; as well as hypersensitivity crossed to other types of membrane such as polycarbonate and polymethyl methylcrylate<span class="elsevierStyleSup">11</span>&#46; These reactions to polysulfone could be different depending on its manufacturer&#46; Therefore&#44; HD sessions using other synthetic dialysers were attempted in cases 1 and 2 without success&#46;</p><p class="elsevierStylePara">Another point of interest is the different sterilisation method of the dialysers&#46; M&#252;ller et al&#46; reported that vapour-sterilisation could increase the dialyser&#8217;s biocompatibility in comparison to sterilisation using ethylene oxide<span class="elsevierStyleSup">12</span>&#46; Golli-Bennour et al&#46; affirmed that the membranes sterilised using vapour increased the viability of the endothelial cells compared to sterilisation methods using radiation or ethylene oxide<span class="elsevierStyleSup">13</span>&#46; In addition&#44; they showed that&#44; according to the sterilisation method&#44; the concentration of serum malondialdehyde&#44; used as a maker for lipid peroxidation&#44; increased substantially with respect to healthy patients when the dialyser&#8217;s sterilisation was by gamma radiation or ethylene oxide&#46; However&#44; other authors have reported that vapour sterilisation does not seem to have an effect on the freeing of pro-inflammatory cytokines&#44; such as interleukin-1&#46; In our patients&#44; membrane sterilisation was heterogeneous&#59; FX and Poliflux dialysers are sterilised using vapour&#44; while cellulose triacetate and Eliseo dialysers are sterilised using gamma rays&#44; making it difficult to establish a causal relationship&#46;</p><p class="elsevierStylePara">A key finding in the cases in our department is that all hypersensitivity reactions disappeared after changing the dialyser to cellulose triacetate&#46; Urbani et al&#46; showed differences between the helixone and cellulose triacetate dialysers when they were studied through proteomics<span class="elsevierStyleSup">14</span>&#46; Abundant proteins involved in the blood-dialyser interaction were found on the helixone membrane&#44; such as ficolin-2 and fibrinogen fragments&#46; Other authors had already demonstrated the absorption of ficolin-2 in polisulfone dialysers&#44; which could contribute to the complement&#8217;s activation&#44; leukocyte adhesion and&#44; at worst&#44; blood coagulation<span class="elsevierStyleSup">15&#44;16</span>&#46; In addition&#44; it was published that cellulose triacetate induces less hypersensitivity reactions&#44; probably due to less activation of the platelet membrane &#40;GpIIb&#47;IIIa&#41;&#44; producing less aggregation disease<span class="elsevierStyleSup">17</span>&#46; The mechanisms making our patients sensitive to the described synthetic dialysers and not to the cellulose triacetate dialyser are not clear&#46; Therefore we are designing specific <span class="elsevierStyleItalic">ex vivo </span>response studies on immunocompetent cells for those patients who showed allergic reaction to synthetic dialysers&#44; as well as cross-sectional response studies on hypersensitivity with various HD membranes&#46;</p><p class="elsevierStylePara">Adverse reactions to dialysers are a severe complication intrinsic to the therapy itself&#46; The nephrologists should be alert to this possibility&#44; acting immediately faced with mere clinical suspicion and referring the patient to the allergy department to complete the study as soon as possible&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">The authors thank Dr&#46; Rafael P&#233;rez Garc&#237;a for his revision and correction of this article&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">La realizaci&#243;n de una sesi&#243;n de hemodi&#225;lisis &#40;HD&#41; supone un cierto riesgo de aparici&#243;n de reacciones adversas de hipersensibilidad&#44; al estar en contacto abundantes cantidades de sangre con diferentes materiales de origen sint&#233;tico&#46; En HD han sido descritas reacciones de hipersensibilidad al &#243;xido de etileno y a membranas no biocompatibles como el cuproamonio&#46; Tambi&#233;n se han comunicado casos de hipersensibilidad con membranas biocompatibles como la polisulfona&#44; e incluso con polisulfona asociada a polivinilpirrolidona&#46; En este art&#237;culo queremos describir seis casos acontecidos en nuestro servicio de reacciones de hipersensibilidad mayoritariamente temprana a la sesi&#243;n de HD&#44; caracterizados por mal estado general&#44; desaturaci&#243;n&#44; broncoespasmo e hipotensi&#243;n arterial&#44; con buena respuesta a la suspensi&#243;n temporal de la sesi&#243;n y con reaparici&#243;n en sesiones posteriores siempre que se utilizase un dializador sint&#233;tico&#46; Todas tienen en com&#250;n no haberse dado de nuevo en sucesivas observaciones cuando las sesiones fueron realizadas con una membrana de celulosa&#46;</p>"
      ]
      "en" => array:1 [
        "resumen" => "<p class="elsevierStylePara">Undergoing a haemodialysis &#40;HD&#41; session poses a certain risk of hypersensitivity adverse reactions as large quantities of blood are in contact with various synthetic materials&#46; Hypersensitivity reactions to ethylene oxide and non-biocompatible membranes&#44; such as cuprophane&#44; have been described in HD&#46; Cases of hypersensitivity with biocompatible membranes&#44; such as polysulfone&#44; and even polysulfone-polyvinylpyrrolidone&#44; have also been reported&#46; In this article we describe six cases of mostly early-stage hypersensitivity reactions to HD occurring in our department&#44; characterised by malaise&#44; desaturation&#44; bronchospasm and arterial hypotension&#44; with good response to the session&#8217;s temporary suspension and with reappearance in subsequent sessions that used a synthetic dialyser&#46; No hypersensitivity reactions reappeared in successive observations when the sessions were carried out using a cellulose membrane&#46;</p>"
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ISSN: 20132514
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