A Curious Case of Dialysis-Associated Reaction

Introduction: Hemodialysis is a renal replacement therapy where the patient’s blood comes in contact with different membranes. This may trigger a cascade of inflammatory responses leading to dialyzer reactions, broadly classified into types A (IgE mediated) and B (complement mediated). Symptoms range from mild itching to dyspnea, hypotension and cardiac arrest. Case Description: Our case is a 53 years old female with Hx of ESRD from DM. She was switched from peritoneal dialysis due to delayed abdominal wound healing. She was tolerating her treatments well without complications. She presented with low back pain and fever and was found to have Tunneled dialysis catheter associated Staph epidermidis bacteremia and was admitted to ICU for septic shock. CRRT was provided ( NXstage machine/gamma sterilized polyether sulfone membrane). As she became hemodynamically stable, dialysis was attempted using Optiflux F160NR single use dialyzer (an ebeam sterilized polysulfone membrane). Within the first few minutes, she developed dyspnea and hypotension requiring prompt cessation of hemodialysis. Dialyzer reaction was suspected. For her second session the filter was prerinsed using sterile normal saline. She tolerated well for the first hour but then developed the same symptoms again. Ultrafiltration was attempted at a rate of 2.5ml/kg/hr which was lower than 10ml/kg/hr ultrafiltration while on CRRT. Her workup showed normal cardiac function,no pericardial effusion and no pulmonary embolism. For her third session, we premedicated her with methyl prednisone, diphenhydramine, and famotidine one hour prior to dialysis. She did not develop symptoms. She received 9 hemodialysis sessions during her hospital course which she tolerated well without complaints. No similar events were recorded in other patients in the unit. We couldn’t reuse filters or obtain a different type per institution policy. Discussion: Our patient's recurring symptoms of dyspnea and hemodynamic instability while receiving intermittent hemodialysis were suggestive of allergic reaction. Cardiac, volume, sepsis, Medication side effects and related etiologies were ruled out. Resolution of her symptoms only after premedicating her with steroids, H1 and H2 antagonists confirmed our suspicions. Dialysis reactions are rare but can cause life-threatening complications and nephrologists need to have a high index of clinical suspicion for timely diagnosis and treatment.