What should be done for a patient experiencing an allergic reaction during hemodialysis?

Management of Allergic Reactions During Hemodialysis

Immediately stop the hemodialysis session and disconnect the patient from the dialysis circuit, as this intervention alone consistently improves symptoms and is the most critical first step specific to dialysis-related allergic reactions. 1

Immediate Recognition and Circuit Disconnection

The dominant clinical findings during hemodialysis allergic reactions include respiratory distress, agitation, pruritus, and blood pressure alterations, with respiratory arrest being a potential life-threatening complication. 1 Disconnecting the patient from the extracorporeal circuit invariably improves symptoms and must be done immediately. 1

Primary Resuscitation (ABC Approach)

Once disconnected from dialysis, follow standard anaphylaxis management protocols:

Airway and Breathing

• Maintain airway patency and administer 100% oxygen 2
• Intubate the trachea if necessary and ventilate with oxygen 2
• Call for help immediately and note the time 2

Circulation and Epinephrine Administration

• Administer intravenous epinephrine 50 mcg (0.5 ml of 1:10,000 solution) as the initial adult dose 2
• Several doses may be required for severe hypotension or bronchospasm 2
• If multiple doses are needed, start an epinephrine infusion (0.05-0.1 mcg/kg/min) due to its short half-life 2, 3
• Elevate the patient's legs if hypotension is present 2

Fluid Resuscitation

• Administer normal saline 0.9% or lactated Ringer's solution as rapid bolus via large-bore IV 2
• Large volumes may be required; escalate up to 20-30 ml/kg if inadequate response 3

Secondary Management

After initial stabilization:

• Administer chlorphenamine 10 mg IV (adult dose) 2
• Administer hydrocortisone 200 mg IV (adult dose) 2
• For refractory hypotension despite epinephrine, add norepinephrine, phenylephrine, or metaraminol infusion 3
• For persistent bronchospasm, administer inhaled or IV salbutamol, or consider aminophylline or magnesium sulfate 2, 3

Diagnostic Blood Sampling

Draw serum mast cell tryptase at three specific time points to confirm the diagnosis: 2, 4

1. First sample: As soon as feasible after resuscitation starts (do not delay resuscitation) 2, 4
2. Second sample: 1-2 hours after symptom onset 2, 4
3. Third sample: At 24 hours or during convalescence to establish baseline levels 2, 4

Label all samples with time and date. 2

Critical Pitfalls and Causative Agents

Common Culprits in Hemodialysis

The dialyzer membrane is the most likely source of allergic reactions during hemodialysis. 1 Specific causes include:

• Ethylene oxide (ETO): Used to sterilize heat-sensitive dialysis filters; switching to steam-sterilized filters resolves ETO-related reactions 5, 6
• Heparin: Contaminated heparin has caused outbreak clusters of allergic reactions during dialysis 7
• Nafamostat mesilate: An anticoagulant alternative that can cause severe reactions including abdominal pain 8

Important Diagnostic Considerations

• RAST testing performed immediately after anaphylaxis may be falsely negative and misleading 6
• Approximately 23.6% of allergic reactions are non-IgE-mediated and will have negative blood tests despite true clinical allergy 4
• Eosinophilia may be present in affected patients, suggesting an allergic mechanism 1

Post-Acute Management

• Observe the patient in a monitored area for minimum 6 hours or until stable and symptoms regressing 3
• Arrange transfer to Critical Care if clinically indicated 2
• For future dialysis sessions, identify and avoid the causative agent (switch dialyzer type, change anticoagulant, or use alternative sterilization method) 5, 8
• Refer patient for formal allergy investigation to identify the specific causative agent 2

Key Clinical Pearls

The reaction typically occurs within minutes of initiating hemodialysis, though onset can be delayed up to one hour with certain substances like latex, antibiotics, IV colloids, and ethylene oxide. 2, 7 The immediate disconnection from the dialysis circuit combined with standard anaphylaxis management (epinephrine, fluids, antihistamines, corticosteroids) addresses both the source and the systemic reaction simultaneously.