Microsoft Word - NEF158BF

F. Caravaca, Serv. Nefrología, Hospital Insalud, cts. Valverde s/n, 06010 Badajoz (Spain) Dear Sir, Hypersensitivity reactions have been described in relationship to hemodialysis procedures. The main substances reported as implicated in these reactions have been: ethylene oxide [1, 2], formaldehyde [3], and Cuprophan [4]. Hanai et al. [5] reported a case of anaphylactic reaction, asthma and eosinophilia related to acetate dialyzate. We want to describe a quite similar case: J.V., a 35-year-old female with end-stage renal disease due to reflux nephropathy. She began a regular hemodialysis program 5 years ago. During this period she did not present major problems. She denied allergic antecedents as well as respiratory complaints. Five minutes after the initation of a hemodialysis, she felt generalized itching, chest discomfort, breathlessness, paresthesia in lower limbs, and on examination showed hypotension and disseminated wheezing. These symptoms improved after turning off the dialyzate delivery. Inquiries into dialysis supplies verified that there had been no changes in the past year (table I). She was taking aluminum hydroxide, 25-hydroxycholecalciferol and multivitamins. An increase in eosinophil counts in the last 3 months was observed (total eosinophil count was 600–700 mm 3). In the next dialysis she developed an anaphylactic shock with glottis edema. To obviate the Cuprophan membrane she was transferred to a hemo-filter using a cellulose acetate membrane and acetate as a replacement buffer, but in the first minute of acetate infusion she began to complain of the same symptomatology. Thus, we thought of an acetate as a possible etiologic agent and it was replaced by lactate. With this change the patient showed a good tolerance to hemo-filtration, but after that time, she began to complain of asthmatic attacks at home, which occurred mainly on the days when she had to dialyze. The following month, the laboratory data showed strong rise in eosinophil count as well as a high serum IgE level (fig. 1). Other causes of hypereosinophilia were discarded. Using the same dia-lyzer and potting material sterilized with gamma rays failed to improve the symptomatology. Thus a broncho-dilator therapy was prescribed. The subsequent evolution (17 months) was characterized by an increase in the frequency of asthmatic attacks, rise in eosinophil counts and IgE level (fig. 1), and chest X-rays disclosed diffuse reticulonodular infiltrations throughout the lung (fig. 2). This progressive deterioration