Anaphylactic reaction to ethylene oxide in a hemodialysis patient

Abstract

We present the case of a patient who developed a severe systemic allergic reaction during initiation of hemodialysis. The reaction completely resolved by switching the dialysis filter sterilized by ethylene oxide to a steam sterilized filter. Ethylene oxide is used to sterilize heat sensitive medical devices, and although allergic reactions related to ethylene oxide have been reported before, awareness is lacking among providers in the inpatient setting, specifically in the intensive care unit setting.

Ethylene oxide‐type hypersensitivity reactions in G‐CSF mobilized, peripheral blood hematopoietic progenitor cell donors and review

“…Interestingly, EtO reactions tended to occur during the “first use” of EtO‐sterilized, reusable hollow‐fiber dialysis filters 6,29,30 . EtO reactions could be averted by extensive rinsing of the dialysis circuit prior to use or by switching to steam‐sterilized or irradiated filters 9,11,22,29 . Today, gamma radiation has largely replaced EtO for sterilization of dialysis membranes with only one published report of EtO‐reaction associated with dialysis after 1986 11 .…”

“…2,16 This was followed by a series of type 1 hypersensitivity reactions, including anaphylactic shock, in chronic dialysis patients in the 1980s (Table 2). [3][4][5][6][7][8][9][10][11]29 By the mid-1980s, EtO hypersensitivity was estimated to result in at least five deaths annually in the United States. 29 Most patients in these early reports had an extensive history of prior dialysis.…”

“…6,29,30 EtO reactions could be averted by extensive rinsing of the dialysis circuit prior to use or by switching to steam-sterilized or irradiated filters. 9,11,22,29 Today, gamma radiation has largely replaced EtO for sterilization of dialysis membranes with only one published report of EtO-reaction associated with dialysis after 1986. 11 Interestingly, this patient was sensitized after only one procedure: She was subsequently switched to steamsterilized dialysis membranes after her third procedure without further events.…”

“…1,2 EtO is widely used to sterilize heat labile plastics, including intravenous tubing and commercial apheresis kits used for apheresis, photopheresis, and blood component collection. 2 Allergic reactions to EtO, including anaphylaxis and death, have been reported in patients undergoing dialysis, [3][4][5][6][7][8][9][10][11] plateletpheresis, 12,13 plasmapheresis, 14 photopheresis, 15 cardiac bypass, 16 EtO-sterilized cardiac stents, 17 and blood transfusion through EtO-sterilized leukofiltration filters. 18 Because such allergic reactions are relatively rare, they can go unrecognized due to lack of awareness and knowledge.…”

Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) – Part I: post-crisis guidelines and treatment

“…Although reactions are rare in the perioperative setting, there appears to be an increased risk of sensitization in patients with myelomeningocele and ventriculoperitoneal shunts, 90 and there are also reports in patients undergoing hemodialysis. 102 The diagnostic test is to search for specific IgE, 103 but the test is not available in Brazil. It is very hard to prevent using ethylene oxide.…”