Haemodialysis-triggered asthma

Thoracic complications in uremic patients and in patients undergoing dialytic treatment: state of the art

No organ in the chest is spared the negative effects of uremia. The dialytic treatment itself is often associated with a large array of thoracic complications. We review the main thoracic manifestations of the terminal uremia from the radiological point of view, such as: uremic pleuritis and pericarditis, uremic pneumonia, renal osteodystrophy, infections, and metastatic pulmonary calcifications. Respiratory function derangement and the problems related to peritoneal dialysis and hemodialysis are discussed in some detail, along with the diagnostic role of plain films, US, nuclear medicine, and CT. The main focus of this review is on the hydration problems and pulmonary edema, often related to a large number of pathogenetic factors. Based on our experience, we think that the chest X-ray is not able to accurately discriminate between cardiogenic edema and fluid overload edema (so-called renal pulmonary edema). The radiological findings of the thoracic complications in uremic patients are multiple and complex but, in most cases, the imaging techniques may offer an accurate and noninvasive diagnostic approach, with a high benefit-cost ratio.

The effect of dialyzer reuse on peak expiratory flow rate

Peak expiratory flow rates were measured during routine haemodialysis in 18 patients with chronic renal failure who were in receipt of thrice weekly haemodialysis treatment, using both a new cuprophan dialyzer and then the same dialyzer after reprocessing. Acetate buffered dialysate was used on both occasions. The peak expiratory flow rates fell by 10 +/- 0.3%, mean +/- sem, during the first hour of treatment with the new dialyzer, and in seven patients (39%) the fall was greater than 15%. Whereas the reduction in peak expiratory flow rates was significantly less with reuse, 4 +/- 0.1% (P less than 0.5). Similarly, the fall in arterial oxygen tension was also reduced on reuse from 28 +/- 1.2% to 14 +/- 1.3% at 30 min (P less than 0.05) and from 30 +/- 1.4% to 18 +/- 3.1% (P less than 0.05) at 60 min of dialysis. There was also a reduction in the fall in the peripheral platelet count at 30 min of dialysis from 14 +/- 0.8% to 9 +/- 0.4% with reuse (P less than 0.05). However, there was no change in dialysis associated leukopenia with reuse of the dialyzer membrane. These results suggest that reprocessing the dialyzer membrane alters its biocompatibility characteristics resulting in an improvement in biocompatibility and further supports the role of inflammatory cell mediator release in the pathogenesis of dialysis associated hypoxaemia and pulmonary dysfunction during the first hour of dialysis treatment.

Fall in peak expiratory flow during haemodialysis in patients with chronic renal failure

Peak expiratory flow rate (PEF) was measured during haemodialysis in 30 unselected patients with chronic renal failure. The patients attended the hospital dialysis unit, where they received regular dialysis using a cuprophan dialyser with acetate buffered dialysate. Mean PEF had fallen by 60 l/min (13%) 30 minutes after the start of dialysis. In 10 of the 30 patients the fall in PEF was over 15%, the maximum fall being 32%. After the initial fall PEF increased throughout the next 2.5 hours of haemodialysis, but it fell again at five hours in the 14 patients who had been dialysed for four hours. During dialysis there was a reduction in blood white cell and platelet counts and in arterial oxygen tension at 30 and 60 minutes (p less than 0.05) and the white cell count and arterial oxygen tension were still reduced at three hours. The coincidence of the fall in PEF at 30 minutes and the fall in arterial oxygen tension suggests that bronchoconstriction might contribute to dialysis induced hypoxaemia by causing ventilation-perfusion disturbances. Appreciable airway dysfunction occurred in all the patients undergoing regular haemodialysis with new cuprophan dialysers and acetate buffered dialysate.

Acute anaphylactoid reactions during hemodialysis in France

A retrospective survey of anaphylactoid reactions during dialysis in France was conducted. In 52 of 112 hemodialysis units surveyed 111 patients who had suffered one or more anaphylactoid reactions during dialysis were identified. According to the Hamilton/Adkinson classification, in 31 patients reactions were minor, in 54 patients moderate, and in 26 patients severe. Four patients died of their reactions. A preponderance of reactions (75 and 11%) occurred with cuprammonium cellulose hollow-fiber and plate dialyzers, respectively. Severe dialyzer reactions were found to occur more frequently after the long (weekend) interdialytic interval. In an in vitro study, six brands of cuprammonium cellulose hollow-fiber dialyzers were rinsed with water and the eluates analyzed by size exclusion chromatography for contaminant particles. Substantial variation in the amount of extractable material was found between dialyzers of different brands, despite the fact that all dialyzers used membranes from the same manufacturer. Previous data by others has suggested that this extractable material is a derivative of cellulose. Results of our epidemiologic survey in France are similar to those previously reported in the United States and suggest an increased incidence of dialyzer reactions with ethylene oxide-sterilized cuprammonium cellulose dialyzers. The presence of cellulose-derived particles in the rinsing fluid of such dialyzers and the possible increased incidence of reactions after the long (weekend) interdialytic interval suggest that allergy to cellulose-derived particles eluted from cellulosic dialyzers may contribute to dialyzer hypersensitivity reactions.

Complement activation and hypersensitivity reactions to dialysis membranes

Certain patients receiving hemodialysis experience recurrent chest pain, dyspnea, and hypotension during exposure to new cuprophane-membrane dialyzers (the "first-use syndrome"). Because activation of complement may be involved in these events, we examined in vivo complement activation with new cuprophane membranes and in vitro activation by zymosan in 6 such patients, and compared them with 10 patients who did not have symptoms during dialysis. All patients with the first-use syndrome had maximal complement activation 10 minutes after initiation of dialysis, with C3a des-arginine (desArg), the stable metabolite of C3 activation, equal to 8533 +/- 157 ng per milliliter (mean +/- S.E.M.). In asymptomatic patients the maximal C3a desArg value occurred at 15 minutes and was only 2907 +/- 372 ng per milliliter (P less than or equal to 0.0001). At a concentration of 3.8 x 10(-5) g of zymosan per milliliter, patients with the first-use syndrome had a C3a desArg level of 29.6 +/- 1.4 micrograms per milliliter, whereas it was only 16.6 +/- 2.3 micrograms per milliliter in asymptomatic patients (P less than or equal to 0.0001). Two other patients, who experienced cardiopulmonary collapse during the first two minutes of dialysis, had a C3a desArg level of 18,900 and 7800 ng per milliliter, respectively. We conclude that the occurrence of adverse symptoms associated with new cuprophane-membrane dialyzers correlates with complement activation.

Plastic filing from dialysis tubing induces prostanoid release from macrophages

Multiorgan, abnormalities in dialysis patients (for example, hepatosplenomegaly, granulomatous hepatitis, cytopenia from hypersplenism) have recently been ascribed to the loading of macrophages (MO) with silicone particles released from the pump segment of dialysis tubing. In the present study, the effect of chronic intravenous or intraperitoneal loading of rats with silicone, polyvinylchloride (PVC) and polyurethane (PU) particles on arachidonic acid metabolism of peritoneal MO and splenic cells was examined in vitro. Intravenous injections of silicone, PVC, or PU particles caused accumulation of the material within the lysosomes of MO of spleen, liver, and lung. Spontaneous release of prostaglandin E2 (PGE2) and thromboxane B2 (TXB2) was significantly increased in peritoneal MO of rats injected with silicone, PVC, or PU (Control: 4.27 +/- 0.85 ng PGE2/ml/24 hr; silicone 51.9 +/- 13.2; PVC 57.5 +/- 10.6; PU 28.8 +/- 2.3). Zymosan or LPS stimulated PGE2 release from control MO, but caused no consistent further elevation of high basal PGE2 release from MO after particle loading. Furthermore, increased spontaneous and stimulated TXB2 release was also observed in spleen cells of rats given intravenous injection of silicone particles. It is concluded that storage of plastic particles (silicone, PVC, and PU) by macrophages stimulates arachidonic acid metabolism.

Symptoms and activation of granulocytes and complement with two dialysis membranes

Complement (C) activation, neutropenia, and mild pulmonary dysfunction attend hemodialysis (HD) with cellophane [for example, cuprophan (Cu)] membranes. While usually asymptomatic, these phenomena may cause distress in patients with cardiopulmonary disease, and "start-up" symptoms of HD might be mediated by C-stimulated granulocytes (PMNs). Cellulose acetate (CA) hemodialysis membranes have been devised and claimed more blood compatible than Cu. In a blinded series of HD patients, pruritus, fatigue, and sense of well-being were each scored statistically more favorably by the patients during HD with CA than during HD with Cu (P less than 0.05). Postulating that less C activation might underlie the benefit, we showed that neutropenia was less severe with CA (nadir 77.6% of initial count, +/- 4 SEM) than with Cu (38.3% +/- 2.9; P less than 0.01). In vitro, incubation of CA membranes with plasma led to less C3 conversion (20% vs. 40%), less PMN aggregating activity (5.9 ZAP units vs. 36.3) and less decrement in CH50 (6.5% vs. 22%) than like incubations of Cu. C activation was also less potent in vivo: During HD plasma C3a rose from a mean 401 ng/ml to a peak 6,325 in patients on Cu dialyzers, but from 426 to only 3,637 in patients on CA devices (P less than 0.05). Time-course studies suggested CA was initially as potent an activator as Cu but rapidly lost ability to activate C, possibly because of saturation of C3b binding sites. As an index of PMN activation, we also assayed plasma lactoferrin and found levels significantly higher during Cu than CA dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaphylactoid reactions due to haemodialysis, haemofiltration, or membrane plasma separation

A previously undescribed anaphylactoid reaction to haemodialysis, haemofiltration, or membrane plasma separation occurred in 15 patients receiving regular dialysis. The illness varied in severity from urticaria, sneezing, and watering of the eyes to severe bronchospasm and cardiovascular collapse, and began within a minute of blood being returned from the dialyser or filtration device to the patient. Reactions developed only when a dialyser sterilised with ethylene oxide was used for the first time and never after sterilisation with formalin. Several patients had more than one reaction while three had a reaction each time a new dialyser was used. Incorrect priming of the dialysers may be a partial explanation of these attacks, but the exact reason for their occurrence is unknown. This is a dramatic and potentially life-threatening syndrome that may not previously have been recognised as a reaction to dialysis.

A study on hemodialysis leukopenia using various dialyzers

Hemodialysis leukopenia was studied using various dialyzers and membranes. We found that dialyzers with cellulosic membranes caused marked leukopenia, but in recently developed non cellulosic membranes, its occurrence was significantly less. Additionally, our results showed a newly developed cellulose acetate membrane to correlate well with the non cellulose membranes regarding leukopenia, in spite of it being a derivative of cellulose. The extent of white blood cell decrease seemed to correlate inversely with an increase in the ultrafiltration rate per membrane area of dialyzer. The relationship between leukopenia and hypoxemia was examined also. The results of this investigation are included, however, we feel that more research is necessary before any conclusions can be made.

Effect of acetate upon arterial gases

Following infusion of sodium acetate, a significant fall in arterial oxygen tension (PO2) was observed (p less than 0.001). A rise in PCO2 or bicarbonate was also statistically significant. pH was however remained unchanged. Though a rise in PCO2, bicarbonate, pH was observed following infusion of sodium bicarbonate, no significant fall in PO2 was observed. These results suggest a role of acetate ion for the fall of arterial oxygen tension; the hemodialysis-induced hypoxemia.