Epidemiologic Notes and Reports
Acute Allergic Reactions Associated with
Reprocessed Hemodialyzers -- Virginia, 1989
From July 18 to November 27, 1989, nine patients had 12 acute
allergic reactions during hemodialysis treatments at a dialysis
center in Virginia. The reactions occurred within 10 minutes of
the initiation of dialysis and were characterized by symptoms
including a sensation of warmth (75%), especially in the hands;
fullness in the mouth or throat (58%); tingling paresthesias
(50%); nausea/vomiting (33%); and tightness in the chest (33%).
Two patients developed angioedema of the lips and tongue; one of
these patients required hospitalization.
All 12 reactions occurred in patients using mechanically
reprocessed dialyzers which had been rinsed with hydrogen
peroxide and filled with a disinfectant (hydrogen peroxide,
peroxyacetic acid) before reuse. When dialysis sessions were
resumed with unused dialyzers, no subsequent reactions occurred.
No reactions occurred among patients receiving dialysis with
unused dialyzers.
Before reuse, all reprocessed dialyzers were rinsed with saline
and had tested negative for residual hydrogen peroxide. Reactions
were not associated with a specific type of dialyzer membrane or
dialysis machine. The Food and Drug Administration (FDA) also has
received reports of similar reactions from dialysis centers in
Oregon and Georgia. CDC and FDA investigations have been
initiated to identify the cause and source of the reactions.
Reported by: GB Miller, Jr, MD, State Epidemiologist, Virginia
State Dept of Health. R Keith Sikes, DVM, State Epidemiologist,
Georgia Dept of Human Resources. Office of Compliance, Center for
Devices and Radiologic Health, Food and Drug Administration.
Hospital Infections Program, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Acute allergic or hypersensitive reactions
infrequently occur in patients during hemodialysis (1) and are
usually attributed to the first use of a dialyzer. The reactions
in this outbreak were unusual because all were associated with
reprocessed dialyzers, occurred within 10 minutes of beginning
dialysis, and were temporally clustered at several hemodialysis
centers. Physicians are requested to report acute allergic
reactions associated with hemodialysis through state health
departments to CDC (CDC telephone: (404) 639-3406).
Reference
Villarroel F, Ciarkowski AA. A survey on hypersensitivity
reactions in hemodialysis. Trans Am Soc Artif Intern Organs
1985;9:231-4.
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