Dr Jessie Madden1, Dr Liam Qi1, Tania Watene2, Julia Jefferis1, Richard Wong3, Richard Baer1
1Department of Nephrology, Mater Health Service, Brisbane, Australia, 2Department of Pharmacy, Mater Health Service, Brisbane, Australia, 3Department of Immunology, Princess Alexandra Hospital & Division of Immunology, Pathology Queensland Central Laboratory, Brisbane, Australia
Biography:
Bio to come
Background:
Hypersensitivity reactions on dialysis are commonly attributed to medications or dialyser cellulose membranes. Here we present a case of haemodialysis-associated anaphylaxis without clear trigger, with successful institution of immunomodulatory therapy including omalizumab.
Case Report:
A 24-year-old female receiving haemodialysis via Permacath in setting of congenital single kidney secondary to OEIS (Omphalocele, Exstrophy of the cloaca, Imperforate Anus and Spinal defects) syndrome presented with escalating allergic reactions. Her history included previous episodes of intraabdominal sepsis, a prior episode of intra-operative anaphylaxis to unknown agent and persistent eosinophilia with stable splenomegaly. Intra-dialysis hypotension (pre-dialysis SBP 90-110mmHg, during dialysis 70-90mmHg) progressively worsened with associated itch, nausea, wheeze and dynamic rise in mast cell tryptase.
Haematological, infective, autoimmune and infiltrative causes for persistent eosinophilia and hypotension were excluded with negative strongyloides serology, ANCA, flow cytometry, PET scan. Echocardiogram was unremarkable. Bone marrow aspirate and trephine revealed normocellular bone marrow with significant marrow eosinophilia. Abnormal mast cells were excluded.
Anaphylaxis was suspected and potential causative agents were systematically excluded: Elisio, Coral, Solacea dialysers, sterilising agents (chlorhexidine, isopropyl alcohol), adhesives, enoxaparin, urokinase and latex. The Permacath model was changed and heparin-only locks were instituted in place of Taurolock Hep500®(heparin 500 units/mL , taurolidine, citrate 4%).
The patient developed worsening dialysis reactions requiring ICU support. In the setting of life-threatening anaphylaxis without a clear trigger, a regimen of loratadine 10mg BD, nizatidine 150mg daily, montelukast 10mg daily, omalizumab 300mg loading with monthly maintenance and IV hydrocortisone 100mg prior to dialysis was instituted. This regimen enabled immediate and safe return to haemodialysis.
Conclusions:
Anaphylaxis on haemodialysis can be life threatening and if the trigger cannot be identified, immunomodulatory therapy can be effective.