Mitigating Risk of Dialyzer Reactions

Introduction: Immediate IgE reactions in dialysis may stem from membranes, sterilants (ethylene oxide), antiseptics (e.g., chlorhexidine), or medications. Though standard polysulfone filters are biocompatible, reactions can occur. Knowledge of filter membranes is critical for addressing allergic risks. Case Description: 71-year-old male with a history of CABG, paroxysmal atrial fibrillation (A fib), and no known allergies, presented with an ST elevation myocardial infarction. His hospital course was complicated by A fib with rapid ventricular response and a left ventricular aneurysm. He developed acute kidney injury from ischemic nephropathy and required hemodialysis (HD). During his first HD session with a polysulfone filter, he immediately experienced body aches, pruritus, nausea, and increased oxygen requirement, so HD was stopped. A Poracton filter was tried, but symptoms recurred without ethylene oxide. Allergy/immunology suspected an IgE-mediated reaction, possibly from prior CABG. Premedications were deemed minimally beneficial. CVVHD was started with an AN-69 (ST 150) filter and tolerated without side effects. Unfortunately, he later passed away due to further cardiac and hepatic complications. Discussion: Knowledge of dialyzer membrane types and biocompatibility profile is key in managing IgE-mediated reactions during dialysis. While most patients tolerate standard polysulfone membranes, mild reactions (e.g., pruritus) may prompt a switch to Poracton filters. If symptoms persist, allergic reaction to ethylene oxide sterilant is unlikely, and non-sulfone-based filters like cellulose triacetate (HD) or AN-69 (CRRT) should be considered. Limited filter availability can delay urgent dialysis; keeping a supply may prevent complications. In cases of immediate IgE reactions, premedication with H1/H2 blockers or steroids may not suffice; filter change is warranted. Epinephrine should be readily available in case of anaphylaxis. Prior exposures, such as CABG, may sensitize patients to materials or sterilants, increasing the risk of allergic responses during dialysis. Characteristics of Different Dialysis Filters - Filter Type Membrane Composition Dialysis Modality Commonly Used Biocompatibility Notes Sterilization Techniques Examples of Common Names Polysulfone Polysulfone iHD High biocompatibility, but may cause allergic reactions in some patients Ethylene Oxide (EtO); Electron Beam Sterilization; Inline Steam Optiflux, FX Series Poracton Polyarylethersulfone (PAES) + Polyvinylpyrrolidone (PVP) iHD High biocompatibility, BPA-free, suitable for sensitive patients Steam Sterilization Revaclear Cellulose Triacetate Modified Cellulose (CTA) iHD Very high biocompatibility, especially for patients intolerant to synthetic membranes Gamma Ray Nipro, Toray Polyarylethersulfone Polyarylethersulfone (PAES) CRRT High biocompatibility, suitable for CRRT in sensitive patients Ethylene Oxide Prismaflex (e.g. HF Filter set) AN69 Acrylonitrile and Sodium Methallyl Sulfonate Copolymer (surface-treated in ST) CRRT Can be surface-treated (ST) to reduce bradykinin generation; ideal for patients with polysulfone allergy Gamma Ray (wet), Ethylene Oxide M/ST Filter Set, Nephral