ReviewHypersensitivity reactions in patients receiving hemodialysis
Introduction
Chronic kidney disease (CKD) remains prevalent at 14.8% in the US general population based on the most recent United States Renal Data System annual report. Within this broad category of patients, those with the most severe renal disease necessitating dialysis have increased in numbers in recent years. As of December 2014, there were 678,383 cases of end-stage renal disease (ESRD), the vast majority of whom were receiving hemodialysis1; this number continues to increase by approximately 21,000 cases per year as a result of the ongoing shortage of organ donors for renal transplantation and the impact of diabetes and hypertension on renal survival. To decrease the morbidity and mortality experienced by patients with CKD resulting from the detrimental effects of the uremic environment, patients on hemodialysis typically receive a large number of medications; this polypharmacy exposure and a recurring in-center “clinic” environment with several possible antigenic exposures and sustained contact with extracorporeal circuits can predispose patients to hypersensitivity reactions.
The increasing prevalence of patients on hemodialysis, the large number of possible causes of hypersensitivity reactions in these patients, and the possible perturbing effect of the uremic milieu on the immune system make it imperative for the allergist to know how to approach the evaluation and management of reactions in this high-risk population.
Section snippets
Categorization of Hypersensitivity Reactions Based on Type of Reaction
The types of reactions experienced by patients receiving hemodialysis can vary from mild (such as contact dermatitis and urticaria) to more serious (such as hypotension and angioedema). Most reactions reported in patients on dialysis are anaphylactic (and pseudoallergic) or delayed-type hypersensitivity (DTH) reactions; for several offending agents, precise mechanistic pathways leading to the reaction have not been clearly elucidated and for some more than one pathway could be in play, as
Conclusion
As has been outlined above, the complexity of care received by patients on hemodialysis and the multiple possible antigenic exposures in these patients make the recognition and management of hypersensitivity reactions challenging yet imperative. Clearly, a thorough history for timing of the reaction and a detailed investigation of all possible exposures, using a multidisciplinary approach, are critical to determine the precise etiology and management of such reactions. As a general measure, for
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Hemodialysis-Related Complement and Contact Pathway Activation and Cardiovascular Risk: A Narrative Review
2021, Kidney MedicineCitation Excerpt :Dialysis-associated reactions are generally acute events, and patients present with a variety of symptoms, ranging from mild (urticaria, erythema, flushing, and fainting) to severe (hypotension, bronchospasm, laryngeal edema, bradycardia, and even cardiac and/or respiratory arrest and death).101 Although there are many different types and potential causes of dialysis-related hypersensitivity reactions, contact activation leading to bradykinin production has been identified as one such mechanism.100-102 Early studies identified negatively charged dialysis membranes, especially the AN-69 membrane, as a source of FXII activation that may promote bradykinin generation, which could lead to acute vasodilation and hypotension.43,44,80
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Disclosures: Authors have nothing to disclose.