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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 29-31

Anaphylactic reaction during hemodialysis on polysulfone membrane in a patient receiving angiotensin II receptor antagonist


Department of Nephrology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China

Date of Web Publication1-Mar-2017

Correspondence Address:
Hao Wang
Department of Nephrology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, 409 Meiling N Rd, Putuo, Shanghai
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.201278

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  Abstract 

Allergic reactions happened during hemodialysis (HD) on polysulfone membrane in a 59-year-old female patient who was being treated with an angiotensin II receptor antagonist, olmesartan, for aggravated hypertension. Anaphylactic reactions including itching, hypoxemia, and facial swelling appeared 1 h after starting the 6th session of HD and lasted for 30 min. When we changed dialyzer and stopped olmesartan for 4 days, the reactions disappeared.

Keywords: Anaphylactic reaction, angiotensin II receptor antagonist, hemodialysis


How to cite this article:
Fang J, Feng L, Wang H. Anaphylactic reaction during hemodialysis on polysulfone membrane in a patient receiving angiotensin II receptor antagonist. J Integr Nephrol Androl 2017;4:29-31

How to cite this URL:
Fang J, Feng L, Wang H. Anaphylactic reaction during hemodialysis on polysulfone membrane in a patient receiving angiotensin II receptor antagonist. J Integr Nephrol Androl [serial online] 2017 [cited 2019 Oct 22];4:29-31. Available from: http://www.journal-ina.com/text.asp?2017/4/1/29/201278


  Introduction Top


It has been well recognized that anaphylactic reactions appear during hemodialysis (HD) using an AN69 membrane in patients who were received angiotensin converting enzyme inhibitors (ACEI).[1] However, anaphylactic reactions rarely happen to patients on angiotensin II receptor antagonists with polysulfone membrane dialyzers. Anaphylactic reactions are divided into Type A (hypersensitivity reactions) and Type B (nonspecific reactions). It is difficult to determine the incidence, due to the lack of uniform criteria for diagnosis and classification. Reported incidence estimates ranged from 3 to 5 out of 100,000 dialysis sessions for severe and nonfatal reactions, to 3–5 out of 100 Type B reactions.[2] To our knowledge, so far there are only three reported cases of possible anaphylactic reactions with the angiotensin II receptor antagonist, losartan.[3],[4] We once reported a patient who had an anaphylactic reaction while she was under dialyzing treatment on polysulfone membrane and receiving olmesartan.


  Case Report Top


A 59-year-old woman at the end-stage renal disease had been on intermittent HD (2–3 times a week) using variable dialyzers. The dialyzers were single use, 1.4 m 2 or 1.5 m 2 and sterilized by Gamma Ray. She had a history of hypertension for 20 years, and received the treatment of a calcium channel blocker (nifedipine controlled release tablets, 30 mg twice a day), but not ACEI or angiotensin II receptor blocker. She had no previous medical history of atopy, asthma and had no allergies to known drugs or foods. Baseline characteristics of the patient are listed in [Table 1]. She had the 4th stage of chronic kidney disease for 3 years. The worsening of renal function (serum creatinine 935 µmol/L, urea 37.8 mmol/L, and urinary protein 5.63 g/24 h) led to the initiation of HD via a temporary catheter placed in the right internal jugular vein, with a cellulose diacetate hollow fiber dialyzer (NIPRO sureflux-150 G, low-flux, 1.5 m 2 surface area, gamma ray sterilized, Kabushiki Kaisha, Japan). The first HD was performed under the prescriptions: Qb 210 mL/min, Qd 500 mL/min, duration of 2 h, with heparin, and with variable ultrafiltration rates. Since she was not on regular HD, the dialyzer was changed to polysulfone membrane (Delan B-14P, low-flux, 1.4 m 2 surface area, gamma ray sterilized, Bain Medical Equipment Limited Company, China) at the 2nd session of HD without changing the other dialysis parameters. No complications were observed. At this time, the patent's 24 h ambulatory blood pressure was poorly controlled: Its average was 166/91 mmHg, so olmesartan 20 mg was added once daily. The 3rd to 5th sessions of HD were also performed with similar prescriptions, with a cellulose diacetate hollow fiber membrane dialyzer. The patient was clinically stable, without any malaise. Five days later, retest blood pressure was 180/80 mmHg, and olmesartan 20 mg were used twice a day. Since she was not on regular HD. Three days later, 1 h after starting the 6th session of HD, with the polysulfone membrane, the patient had a severe anaphylactic reaction. Clinical manifestations included itching, hypoxemia, and facial swelling. The treatment was carried out using intravenous steroids, antihistamines, and oxygen; finally, the HD was completed without the returning of blood. That was a prompt improvement of patient's symptoms. The initial laboratory data after HD showed: Leukocytes 20.3 × 109/L (90% neutrophils; 1.5% eosinophils), hemoglobin 75 g/L, and platelets 113 × 109/L, sodium 138 mmol/L, potassium 4.3 mmol/L, calcium 2.27 mmol/L, urea 18.5 mmol/L, creatinine 616 µmol/L, C-reactive protein (CRP) 13 mg/L, and IgE 932 IU/mL (normal range: <87 IU/mL). The serum complement was normal (C3 97.7 mg/dL and C4 27.3 mg/dL) and the analysis of water supply used for dialysate production revealed 3 CFU/mL and endotoxins <1 EU/mL [Table 2].
Table 1: Baseline characteristics of the patient

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Table 2: Hemodialysis sessions, dialyzers used, and findings observed

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Considering that the hypothesis of an anaphylactic reaction was induced by olmesartan, it was stopped for 4 days. At the next HD session, despite the prerinsing of the dialyzer with 2 L of normal saline and premedication with steroids and antihistamines, the dialyzer membrane was then changed to a nitrocellulose membrane (NIPRO sureflux-150 G, lowe-flux, 1.5 m 2 of surface area, Kabushiki Kaisha, Japan) and no anaphylactic reaction was observed. In the later process of HD, without the use of antiallergic drugs, dialyzer allergic reactions did not happen again.


  Discussion Top


The biocompatibility of the whole dialyzer is determined by several variables: Membrane polymer, potting compound, sterilization, and reprocessing techniques. In general, acute dialyzer reactions are uncommon, and their incidence has declined over the past decades. A typical cause of these reactions is the ethylene oxide (ETO). The dialyzers used in this case were not ETO-sterilized, but the other HD apparatus, such as blood tubing sets in this case. It was found that prerinsing of the dialyzer blood compartment with at least 2 L of saline and of the dialysis fluid compartment by circulation of 500 mL/min of dialysate for 30 min before dialysis can reduce residual ETO to acceptable levels and enhance the removal of other compounds that may leach from filter materials.[5] The first membrane used in this case was a low flux dialyzer, and the routine analysis of the hemodialysis water showed <10 CFU/mL and endotoxins <1 EU/mL, which conforms to the Chinese hemodialysis legislation. The dialyzers and blood tubing sets were not reused and the dialysate was generated using dry bicarbonate.[6] Moreover, acute-phase proteins levels, for example, CRP, were normal, making it unlikely that the microcontamination of the dialysate played a significant role in this case. Meanwhile, there was no symptom of fever, coughing, diarrhea, urinary urgency, and other acute inflammation during the percentage increase of white blood cell and neutrophil in this sample patient case. It might be caused by the usage of glucocorticoids. Other substances can also precipitate anaphylactic reactions, for example, heparin, both unfractionated heparin as the low-molecular-weight heparin.[7] In this case, when low-molecular-weight heparin before hemodialysis used, stop using the olmesartan, continue to use the same low molecular heparin. Hemodialysis allergic reactions did not happen; therefore, heparin was ruled out because the low molecular heparin may cause allergic reactions in hemodialysis.

Anaphylaxis has commonly been described with AN69 dialyzer in ACEI treated patients. Although Wakasa et al. did not find that there is any effect for ACEI on bradykinin production in patients on HD,[8] some researchers suggest that high bradykinin levels are responsible for the anaphylactic reactions possibly due to synthesis of bradykinin by the AN69 membrane along with reduced degradation by the presence of ACEI.[9] Therefore, we believe that ACEI may have some effects on bradykinin levels in patients who have anaphylactic reactions on HD. However, angiotensin II receptor antagonists have no effect on bradykinin metabolism. Our patient developed the anaphylactic reaction while on olmesartan. In conclusion, we, therefore, recommend caution in using angiotensin II receptor antagonists in patients using polysulfone membrane dialyzers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Verresen L, Waer M, Vanrenterghem Y, Michielsen P. Angiotensin-converting-enzyme inhibitors and anaphylactoid reactions to high-flux membrane dialysis. Lancet 1990;336:1360-2.  Back to cited text no. 1
    
2.
Daugirdas JT, Ing TS. First-use reactions during hemodialysis: A definition of subtypes. Kidney Int 1988;24:S37-43.  Back to cited text no. 2
    
3.
Saracho R, Martin-Malo A, Martinez I, Aljama P, Montenegro J. Evaluation of the losartan in hemodialysis (ELHE) study. Kidney Int Suppl 1998;68:S125-9.  Back to cited text no. 3
    
4.
John B, Anijeet HK, Ahmad R. Anaphylactic reaction during haemodialysis on AN69 membrane in a patient receiving angiotensin II receptor antagonist. Nephrol Dial Transplant 2001;16:1955-6.  Back to cited text no. 4
    
5.
Bommer J, Ritz E. Ethylene oxide (ETO) as a major cause of anaphylactoid reactions in dialysis (a review). Artif Organs 1987;11:111-7.  Back to cited text no. 5
    
6.
Ledebo I, Nystrand R. Defining the microbiological quality of dialysis fluid. Artif Organs 1999;23:37-43.  Back to cited text no. 6
    
7.
Ueda A, Nagase S, Morito N, Yotsumoto M, Ohba S, Hasegawa Y, et al. Anaphylactoid reaction induced by low-molecular-weight heparin in a hemodialysis patient. Nephron 2001;87:93-4.  Back to cited text no. 7
    
8.
Wakasa M, Akizawa T, Kinugasa E, Koshikawa S. Plasma bradykinin levels during hemodialysis with PAN DX and polysulfone membranes with and without concurrent ACE inhibitor. Clin Nephrol 1995;44 Suppl 1:S29-32.  Back to cited text no. 8
    
9.
Lemke HD, Fink E. Accumulation of the bradykinin formed by the AN69 or PAN17 Dx membrane in vitro. J Am Soc Nephrol 1992;3:376.  Back to cited text no. 9
    



 
 
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