Anaphylaxis secondary to citric acid allergy in End Stage Renal Disease patient

Dialysis reactions are not uncommon in End Stage Renal Disease (ESRD) patients who are undergoing in-center hemodialysis. Here we report the first case of anaphylaxis related to citric acid solutions used for dialysis machine disinfection and descaling. The patient developed repeated episodes of anaphylactic reactions during hemodialysis only in the inpatient setting leading to respiratory failure needing intubation and anaphylactic shock. This had failed to resolve despite using various combinations of different dialysis machines and dialyzer membranes and only resolved after the elimination of citric acid from the dialysis circuit. This case highlights the importance of different allergens in dialysis circuits and emphasizes the importance of looking for alternative reasons for dialyzer reactions.