Association of ethylene-oxide-induced IgE antibodies with symptoms in dialysis patients

Integrative literature review: Ethylene oxide exposure signs and symptoms

BACKGROUND

Although ethylene oxide (EtO) gas is designated as a human carcinogen, extant literature reports mixed findings on the health effects of exposure. The disparate findings may reflect industry bias as many studies were funded by a large chemical industry lobby.

OBJECTIVE

To conduct an integrative review of studies free from industry bias to facilitate compilation of a comprehensive list of reported signs and symptoms of EtO exposure.

METHODS

We reviewed 1887 papers of which 42 articles met inclusion criteria. The authors conducted this review in accordance with PRISMA guidelines. The presence of bias was assessed using Joanna Briggs Institute checklists.

RESULTS

Non-industry biased literature confirmed serious adverse health effects associated with EtO exposure at the occupational, hospital, and community level. EtO represents a carcinogen, neurotoxin, and respiratory irritant.

CONCLUSION

After removal of industry-biased studies, EtO was unequivocally found to pose a threat to human health. There remains a gap in the number of studies examining community-level exposure, which is essential to understanding the impact of EtO. Given that EtO-emitting facilities are concentrated in diverse and disadvantaged communities, further study of EtO exposure health effects is warranted to inform public policy on toxic air emissions.

Ethylene oxide-type hypersensitivity reactions in G-CSF mobilized, peripheral blood hematopoietic progenitor cell donors and review

BACKGROUND

Ethylene oxide (EtO) is a volatile, ringed toxic ether used to sterilize heat-labile plastics including apheresis sets. In the 1980s, EtO-associated severe hypersensitivity reactions during hemodialysis led to widespread adoption of alternative sterilization for dialysis kits but not apheresis tubing sets. We now report several cases of EtO-type hypersensitivity reactions in autologous donors undergoing hematopoietic progenitor cell collection (HPCC).

MATERIALS AND METHODS

A 10-year retrospective review of allergic EtO-type reactions in adults undergoing HPCC on the COBE Spectra and SPECTRA Optia was performed. Donor medical history and absolute eosinophil counts were compared between cases and 34 HPCC controls. Published EtO reactions during extracorporeal procedures were reviewed with statistical analysis. Graphics and statistics were performed using commercial software.

RESULTS

Three autologous HPCC donors experienced EtO-type reactions within 15 min of initiating HPCC, for a 10-year incident rate of 0.08% per procedure and 0.18% per donor. All three reactions occurred using the Spectra Optia and IDL tubing set, for an Optia/IDL specific rate of 0.2% per procedure and 0.5% per donor. There was no correlation between EtO reactions, eosinophil counts, or saline prime dwell times. No patient had classic predisposing risk factors for EtO hypersensitivity. Two patients required medical intervention whereas the third responded by pausing the procedure and slowing the inlet rate.

CONCLUSION

EtO-type hypersensitivity reactions can be observed during HPCC, especially with the Optia IDL tubing set. EtO reactions may be missed due to their rarity and staff unfamiliarity with this clinical entity.

A new immune-toxicological test for polysulfone hypersensitivity in hemodialysis patients

Incompatibility of dialysis procedure due to hypersensitivity against dialyzer material, currently mainly based on polysulfone and derivatives, cannot be assessed by routine laboratory tests. Although the frequency of such symptoms is suspected to be lower than 2%, it resembles an important clinical problem because dialysis procedures are frequently accompanied by symptoms of non-tolerability with reasons not being entirely clear. To enlighten the role of polysulfone hypersensitivity, we adapted known standardized material immune-toxicological tests (lymphocyte transformation test, basophil degranulation test) to the specific conditions of dialysis and polysulfone material sensitivity. We developed a method of polysulfone micronisation and measured humoral immune response of isolated patient's lymphocytes when incubated with polysulfone dispersion. Thirty-nine samples from 103 patients with suspected polysulfone hypersensitivity within the dialysis population of a nation-wide dialysis provider (n = 15.761 patients) showed positive results for type 1 (n = 19), type 4 (n = 18) or both type (n = 2) reactions. This is the first methodological report showing plausible in-vitro results of patients' samples concerning polysulfone intolerance. Further clinical and laboratory research is needed to define true polysulfone hypersensitivity and to enlighten the field of hypothetic subclinical material incompatibility in patients with impaired dialysis tolerability.

Eosinophilia and Kidney Disease: More than Just an Incidental Finding?

Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.

Increased prevalence of eosinophilia in a hemodialysis population: Longitudinal and case control studies

Eosinophilia is commonly found in patients with clinical reactions to the hemodialysis circuit. With modern membranes, such reactions have become less common, but they may be under diagnosed in patients with subtle symptoms, in whom the presence of eosinophilia is an important diagnostic feature. Two case reports are presented, along with a hemodialysis study of the frequency and clinical associations of eosinophilia. In three hemodialysis facilities, all current hemodialysis patients with persistent eosinophilia (greater than 1 × 10(9) /L for 3 months) were identified. Control patients without eosinophilia (less than 0.5 × 10(9) /L for 3 months) matched for age, gender, and ethnicity were identified from the same facilities. A historical cohort of patients, dialyzing at the same facilities 5 years ago, was screened for the presence of persistent eosinophilia. From 510 patients, 24 cases of persistent eosinophilia were identified (4.7%). The median eosinophil count was 1.75 × 10(9) /L (range 1.1-7.5 × 10(9) /L). The prevalence in a historical cohort 5 years previously was significantly less at 1.5% (P = 0.046). Compared to controls, patients with eosinophilia were more likely to be on an angiotensin converting enzyme inhibitor (41.7% vs. 12.5%, P = 0.049), had a lower C-reactive protein (10 vs. 24 mg/L, P = 0.02) and were more likely to be using a fistula for access (P = 0.049). Over the following 12 months, there was no difference in the mean number of hospital admission days between cases and controls (7.6 vs. 11.5 days, P = 0.54), and no difference in mortality over 29 months (25.0% vs. 29.2%, P = 1.00). Eosinophilia remains not uncommon in hemodialysis patients, and in most cases reflects allergy to components of the dialysis circuit, which is usually subclinical. The overall prognosis for asymptomatic patients appears to be favourable.

Ethylene oxide allergy in patients on hemodialysis waiting for kidney transplantation: logistical nightmare or challenge? A case report

Ethylene oxide (EO) is widely used as a sterilization gas for heat-sensitive devices. In EO-sensitized patients, this type of sterilization can cause rare but major allergic reactions such as hives, rash, asthma, or anaphylactic shock. Hemodialysis patients in particular are at risk of developing hypersensitivity to EO. In these patients, surgical interventions should be planned far in advance allowing a thorough EO-free preparation of all equipment needed for the surgery as well as for the pre-, peri-, and postoperative care. In contrast to elective surgery, kidney transplantation with allografts from deceased donors cannot be planned; exact timing is unpredictable. Furthermore, transplantation may take place years after patients have been put on the waiting list. Listing of patients sensitive for EO is therefore a logistical and medical challenge for all health care professionals involved in the patient's care (eg, surgeons, nephrologists, anesthetists, nurses, pharmacists, and sterilization specialists). This case report describes a patient with chronic kidney disease stage V who developed EO allergy during hemodialysis while waiting for a kidney transplantation. Diagnosis was made based on clinical signs and confirmed biochemically (including a positive radioallergosorbent test). Because the only treatment is avoidance of contact with EO-sterilized materials, a strict EO-free protocol was developed to allow an uneventful transplantation thereafter. Subsequently, 4 newly diagnosed EO-sensitive patients on the active kidney transplantation waiting list were diagnosed, and 1 of these patients has been transplanted successfully. EO allergy in patients on the waiting list for kidney transplantation is a unique challenging situation which, to the best of our knowledge, has not been reported yet for kidney transplantation. This report further highlights the logistical preparation of a renal transplantation, including anesthesiologic, surgical, and postoperative care.

Heparin-induced anaphylactic and anaphylactoid reactions: two distinct but overlapping syndromes

BACKGROUND

Heparin-induced anaphylactic and anaphylactoid reactions are of increasing clinical and scientific interest, particularly given the recent identification of a syndrome of heparin-induced anaphylaxis due to oversulfated chondroitin sulfate (OSCS), a contaminant in certain heparin preparations. However, heparin-induced anaphylactoid reactions also have been reported to be a consequence of immune-mediated heparin-induced thrombocytopenia (HIT).

OBJECTIVE

To summarize the clinical features and pathophysiology of two distinct disorders, HIT-associated anaphylactoid reactions as well as anaphylaxis resulting from OSCS-contaminated heparin.

METHODS

We review literature describing these two types of heparin-induced anaphylactic and anaphylactoid reactions, and seek potential pathophysiologic links between them.

RESULTS

Intravenous bolus heparin administered to patients with circulating 'HIT antibodies', usually as a result of recent heparin therapy, can produce anaphylactoid reactions, probably as a consequence of in vivo activation of platelets and, possibly, leukocytes. Affected patients often evince fever/chills, hypertension and/or acute respiratory compromise ('pseudo-pulmonary embolism'). In contrast, heparin-induced anaphylaxis is caused by activation of the contact system, with formation of vasoactive kinins (bradykinin, des-arg(9)-bradykinin). This latter syndrome has been linked in an epidemic form to administration of OSCS-contaminated heparin; these reactions feature prominent hypotension and laryngeal edema. Hemodialysis patients are at increased risk for both syndromes. There is evidence that OSCS-contaminated heparin itself increases the risk of HIT compared with non-contaminated heparin.

CONCLUSION

Two distinct syndromes of heparin-induced anaphylaxis and anaphylactoid reactions exist. These seem to share certain epidemiologic features, given that OSCS-contaminated heparin can produce anaphylaxis through contact system activation but also could increase risk of HIT and HIT-associated anaphylactoid reactions.

Haemodialysis-associated anaphylactic and anaphylactoid reactions

Anaphylactic and anaphylactoid reactions related to haemodialysis have been increasingly described for almost 3 decades. The majority of these cases used to occur with ethylene oxide sterilized, and complement-activating cellulose membranes. However, a considerable number of publications have focused on polyacrylonitrile AN69 high flux membranes, angiotensin converting enzyme inhibitors and iron as other important causes of potentially severe haemodialysis-related anaphylactoid reactions. Clinical manifestations vary considerably and generally do not allow differentiation between IgE-mediated anaphylaxis and anaphylactoid reactions (e.g. from nonspecific mediator release). Successful management of these patients requires multidisciplinary approach and involves prompt recognition and treatment by the attending physician, and identification of the offending agent(s) with subsequent avoidance of the incriminated compound(s). This review focuses on some major causes of anaphylactoid and anaphylactic reactions during haemodialysis. Special consideration is given to the therapeutic and diagnostic approach.

Soluble CD23 as an effector of immune dysregulation in chronic uremia and dialysis

Patients with chronic renal failure often present an immunodeficiency state paradoxically exacerbated by hemodialysis and associated with signs of T cell activation. The presence of circulating monokines suggests that monocytes are also activated. Whether or not this includes B cells is controversial, despite frequently abnormal antibody responses. We thus investigated whether the soluble low-affinity receptor for IgE (Fc epsilon RII/CD23), recently identified as a marker of B cell and monocyte activation and possibly involved in T cell activation, was modulated by chronic renal failure and hemodialysis. Relative to values in healthy individuals (N = 31), plasma concentrations of soluble CD23 were significantly elevated in non-dialyzed chronically uremic patients (N = 44), more elevated in patients on peritoneal dialysis (N = 24), and most elevated in those on regular hemodialysis (N = 132), stabilizing after about six months. Soluble CD23 levels were unmodified by the first dialysis session but rose markedly during regular dialysis with cellulose or polysulfone membranes, but not with polyacrilonitrile AN-69 membranes. Soluble CD23 levels correlated with levels of IgG, and those of tumor necrosis factor alpha and interleukin-6, suggesting that increased sCD23 levels reflect activation of B cells and monocytes, respectively. These findings reinforce the view of soluble CD23 as a multi-functional receptor/cytokine, and provide evidence that it might contribute to the immune dysregulation associated with chronic renal failure and exacerbated by hemodialysis.

Persistent asthma after accidental exposure to ethylene oxide

Images

Biocompatibility issues in hemodialysis

Hemodialysis, as a life-saving treatment modality for uremic patients, implies a repeated and compulsory contact of blood with foreign materials. As a consequence, biocompatibility problems are unavoidable. The same applies for the material used for the creation of vascular access, and for the alternative dialysis method, CAPD (continuous ambulatory peritoneal dialysis), although each system might cause its own and specific problems. Although in early dialysis the focus has been on maintenance of life and elimination of toxins, later on the important morbid implications of this lack of biocompatibility have been recognized. Eight major problems will be discussed, especially in the perspective of recent new findings in this field: (1) coagulation and clotting; (2) complement and leukocyte activation; (3) susceptibility to infection; (4) leaching or spallation; (5) surface alterations of solid materials; (6) allergic reactions; (7) shear; (8) transfer of compounds from contaminated dialysate. After description of the major biochemical and clinical implications of these problems, ways to prevent morbid events and future perspectives will be described.

High in vitro spontaneous histamine release in long-term hemodialyzed patients

Adverse reactions, such as skin flush and pruritus, have been observed among hemodialyzed (HD) patients. A potential relationship between hemodialysis and allergic phenomena prompted us to investigate some allergologic parameters. Total IgE, specific IgE antiethylene oxide and anti-isocyanate toluene diisocyanate, and in vitro spontaneous histamine release (SHR) were measured in 105 long-term stable HD patients. Thirty-two of the patients had occasionally developed skin flush reactions and/or pruritus during dialysis sessions. Blood samples were taken at the start of dialysis, sera were kept frozen until assay, and in vitro SHR was performed on washed leukocytes at 37 degrees C for 40 minutes. A high (range, 20% to 80%) and reproducible in vitro SHR was observed among 24% of patients. No correlation was found between SHR and the type of dialysis membrane used (copolymer of acrylonitrile-methallyl-sodium sulfonate, cuprophan, and polysulfone). High SHR (i.e., greater than 20%) was observed mainly among patients with detectable antiethylene oxide IgE antibodies (p less than 0.001). High levels of IgE (greater than 300 ng/ml), specific IgE antibodies, and a high in vitro SHR were all observed concomitantly in 26% of the patients with skin flush reactions and/or pruritus, whereas all three of these parameters together were present in only 3% of the symptom-free patients. To our knowledge, this is the first time that a high in vitro SHR has been described among HD patients, and putative correlations with in vivo phenomena are discussed.

Longitudinal study of specific IgE and IgG antibodies in a patient sensitized to ethylene oxide through dialysis

IgE and IgG antibodies to ethylene oxide (EO) were monitored by RAST and by ELISA in serum from a patient with hypersensitivity reactions during hemodialysis. Serum samples from the patient covering a 7-year period were analyzed. The changes in titers of IgE and IgG antibodies correlated to the time of EO exposure as well as to clinical symptoms. EO-specific IgG antibodies were, however, also found in sera from hemodialysis patients without any hypersensitivity symptoms. Assay of specific IgG antibodies will only indicate whether a patient has been exposed to, and immunostimulated by, EO, whereas specific IgE antibodies appear to be clearly related to hypersensitivity symptoms. The hapten and carrier specificity of EO-induced IgE antibodies was studied. The antibodies were found to be solely hapten specific because carriers of different types could be used in RAST without changing the outcome of the test. The existence of new antigenic determinants related to the carrier could not be demonstrated.

Possible role of capillary action in pathogenesis of experimental catheter-associated dermal tunnel infections

An animal model of vascular-catheter-associated dermal tunnel infections was developed to study the pathogenesis of such infections. Bacteria inoculated onto entry sites of catheters into skin could be identified by culture and Gram stain on the tips of plastic catheters (4 cm from the entry site) within 1 h of inoculation, whether the animal was inoculated at the time of insertion of the catheter or 1 week afterwards. Histological examination of dermal tunnels revealed that the introduction of bacteria preceded the development of tissue inflammation. Bacteria on entry sites of percutaneous catheters moved rapidly from the entry site into the dermal tunnel along the external catheter surface, perhaps suspended in a fluid phase and propelled by capillary action.

Ethylene oxide (ETO) as a major cause of anaphylactoid reactions in dialysis (a review)

Ethylene oxide (ETO), an alkylating compound of high chemical reactivity, is widely used for gas sterilization, but recently serious ETO side reactions have been recognized. With chronic ETO exposure, increased spontaneous abortion, sister chromatid exchange, and leukemia are observed. After medical use of ETO outside nephrology, contact dermatitis, cardiopulmonary shock (during cardiopulmonary surgery), allergic local reactions to ETO sterilized lenses, and anaphylactoid reactions to ETO sterilized catheters have been described. In numerous dialysis patients widespread hypersensitivity to ETO has been documented by skin prick test and ETO radioallergosorbent test (RAST). Furthermore an anaphylactoid "first-use reaction" was described in dialyzed patients, most of whom were using hollow-fiber dialyzers. After long discussions whether complement activation versus hypersensitivity is the cause of such acute anaphylactoid reactions, more recent studies using either ETO RAST or basophil degranulation tests implicate ETO hypersensitivity as their major cause. The high prevalence of sensitization to ETO and the frequency, unpredictability, and potential danger of anaphylactoid reactions to ETO lead to the conclusion that ETO sterilization of dialyzers should be discontinued, since alternative modalities of sterilization are currently available.

Ethylene oxide in dialyzer rinsing fluid: effect of rinsing technique, dialyzer storage time, and potting compound

Ethylene oxide (ETO) is recognized as one of the main causes of dialyzer-associated hypersensitivity reactions. We studied the amount of ETO in the rinsing fluid of ETO-sterilized hollow-fiber dialyzers as a function of rinsing technique, dialyzer storage time, and the amount of potting compound (known to be an ETO reservoir) in the dialyzer. The results suggested that the initial 500 ml of rinsing fluid removes much of the residual ETO in the dialyzer. Ethylene oxide extraction was enhanced substantially by rinsing at 37 degrees C versus 5 degrees C. However, considerable amounts of ETO remained in the dialyzer after an initial 500 ml rinse, some of which could be removed by rinsing with an additional 1,500 ml. High concentrations of ETO were measured in fluid that had been recirculated through the dialyzer for 10 min or longer and in fluid that had been allowed to remain in the dialyzer for 10 min under zero-flow conditions. The amount of ETO in the rinsing fluid decreased markedly as the dialyzer storage time was increased from 4 to 8 weeks and in dialyzers in which a portion of the potting compound had been replaced with a polycarbonate ring. Our results suggest that the dose of ETO administered to the patient at the outset of dialysis can be minimized by rinsing the dialyzer with 2 L of fluid at 37 degrees C and by avoiding administration of rinsing fluid that has been allowed to remain in contact with the dialyzer for more than several minutes. Use of a long storage interval and use of dialyzers containing reduced amounts of potting material will also reduce the ETO load.

Mediation of hypersensitivity reactions during hemodialysis by IgE antibodies against ethylene oxide

Sera from 329 hemodialysis patients, 46 of whom had experienced a hypersensitivity-type reaction during hemodialysis, were screened by an enzyme-allergosorbent test (EAST) for IgE antibodies specific for ethylene oxide (ETO). In seven of nine patients who had experienced a severe hypersensitivity reaction (type II or type III), high titers of IgE antibodies against ETO (greater than 3.0 PRU/mL) were found. However, plasma levels of IgE specific for ETO were in the normal range (less than 0.35 PRU/mL) in most (30/37) patients who had experienced a mild (type I) reaction. Selected sera from patients who had experienced severe reactions were further examined for IgE directed against isopropyl myristate (IPM), 2-chloroethanol, and extracts from unsterilized dialyzers. Importantly elevated serum levels of specific IgE against these substances could not be documented. Extracts of an ETO-sterilized, hollow-fiber dialyzer were positive, whereas extracts of an ETO-sterilized dialyzer containing a flat membrane were negative in the EAST. This difference can be explained by the different amounts of ETO present in the dialyzers. We conclude that ETO causes most severe hypersensitivity reactions by an IgE-mediated mechanism. On the other hand, the pathogenesis of mild (type I) reactions is less clearly associated with ETO allergy. Our results also suggest that other potentially allergenic substances in dialyzers (e.g., IPM, 2-chloroethanol) rarely induce specific IgE antibodies in dialysis patients.

Allergic reactions in healthy plateletpheresis donors caused by sensitization to ethylene oxide gas

We observed immediate-type hypersensitivity reactions in 6 of 600 donors who underwent automated plateletpheresis procedures. Ethylene oxide gas, which was used to sterilize plastic components in the disposable apheresis kits, represented a possible source of sensitization. In skin-prick testing, 4 of the 6 donors who had had a hypersensitivity reaction and none of 40 controls who had not had such a reaction had positive tests when an ethylene oxide-human serum albumin reagent was used (P less than 0.001). Radioallergosorbent testing revealed that serum from 4 of the 6 donors who had reactions, but from only 1 of 145 controls, contained IgE antibodies to ethylene oxide-albumin (P less than 0.001). All six of the donors who had reactions had specific ethylene oxide-induced basophil histamine release (mean release [+/- SE], 34.2 +/- 5.6 percent), whereas none of four controls had specific histamine release in response to ethylene oxide (mean release, 5.7 +/- 1.2 percent; P less than 0.005). Repeat plateletpheresis in five of the donors who reacted was accompanied by a recurrence of mild allergic symptoms. These studies demonstrate that sensitization to ethylene oxide gas can occur in healthy plateletpheresis donors and that it may result in immediate hypersensitivity reactions during the donation. The prevalence of such reactions was 1.0 percent in our apheresis donor population.