Anaphylactoid reaction during first hemofiltrationwith a PUREMA polysulfone membrane.

Adverse reactions during hemodialysis are extremely common and include a wide range of clinical presentations from mild to life threatening. We present a case of a 34 year old woman in the Burn Intensive Care Unit, who developed acute kidney injury requiring renal replacement therapy. She was placed on continuous veno-venous hemofiltration with the NxStage machine which uses a synthetic PUREMA polyethersulfone filter sterilized by gamma radiation. Within two minutes of initiating hemofiltration, the patient complained of pruritus as well as dyspnea and became flushed and agitated. She subsequently developed hypotension ultimately resulting in cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and the patient was given epinephrine with return of spontaneous circulation. The following day, the patient was rechallenged with a PUREMA filter, and had a similar reaction with flushing, dyspnea, pruritus and hypotension requiring treatment to be discontinued. The patient was transitioned to the Prismaflex filter, another synthetic membrane, which she tolerated well and continued to utilize through the remainder of her hospital course without complication. Her clinical presentation was consistent with an anaphylactoid reaction, though a tryptase level was not obtained and a radioallergosorbent test performed with membrane material was negative. This case shows the difficulty of identifying the cause of hypersensitivity reactions involving synthetic membranes not sterilized by ethylene oxide, a commonly use sterilizing agent known to cause hypersensitivity reactions. This rare, but potentially fatal reaction has not previously been reported with a PUREMA filter and this case should raise awareness of hypersensitivity reactions with this widely used method of renal replacement therapy.

Continuous renal replacement therapy improves survival in severely burned military casualties with acute kidney injury.

BACKGROUND: Acute kidney injury in severely burned patients is associated with high mortality. We wondered whether early use of continuous renal replacement therapy (CRRT) changes outcomes in severely burned military casualties with predetermined criteria for acute kidney injury. METHODS: Between November 2005 and June 2007, casualties admitted to our burn intensive care unit after sustaining burns in Iraq and Afghanistan, who subsequently developed acute kidney injury or circulatory shock or both, underwent CRRT. Baseline demographic, laboratory, and hemodynamic parameters were recorded. Both 28-day mortality and in- hospital mortality were evaluated and compared with a consecutive group of burn casualties with greater than 40% total body surface area (TBSA) burns, acute kidney injury, or nephrology consultation in the 2 years before the existence of our CRRT program. RESULTS: One hundred forty-seven severely burned military casualties were admitted to our intensive care unit before CRRT program initiation, and 102 were admitted after CRRT program initiation. Before the CRRT program, 16 patients were identified as having >40% TBSA burns with kidney injury with or without nephrology consultation (control group); 18 were treated with CRRT since (CRRT group). Groups were similar for %TBSA, %full-thickness TBSA, incidence of inhalation injury, blood urea nitrogen, creatinine, and Injury Severity Score. Of the CRRT patients, seven soldiers were treated for isolated acute kidney injury, whereas 11 were treated for a combination of acute kidney injury and shock. The dose of therapy was 50.2 +/- 13 mL/kg/h with a treatment course of 5.2 +/- 3 days. Of the 11 patients in the CRRT group treated for shock, eight were off vasopressors by 24 hours and the remaining three within 48 hours. None of the patients in the control group were placed on renal replacement therapy with nephrology consultation in eight patients. Both 28-day mortality (22% vs. 75%, p = 0.002) and in-hospital mortality (56% vs. 88%, p = 0.04) were lower in the CRRT group compared with that in the control group. CONCLUSION: Aggressive application of CRRT in severely burned casualties with kidney injury significantly improves survival.