JOURNAL OF DIALYSIS, 3(1), 73-87 (1979)

EOSINOPHILIA IN MAINTENANCE HEMODIALYSIS PATIENTS

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

Wendy E. Hoy and Rafael V.M. Cestero Strong Memorial Hospital and Monroe Community Hospital, University o f Rochester, Rochester, N.Y. ABSTRACT Peripheral blood eosinophilia was noted in 38% of a group o f maintenance hemodialysis patients, and documented by bone marrow examination. The prevalence o f eosinophilia rose with increasing time on hemodialysis. In 3 subjects the phenomenon appeared to be related to dialysis equipment, but the relationship was less clear in the group as a whole. Severe hypersensitivity reactions during dialysis occurred in 2 patients with marked eosinophilia. Possible causes o f sensitization in maintenance hemodialysis patients are discussed. INTRODUCTION Hypersensitivity reactions associated with eosinophilia were observed in two patients during hemodialysis, and marked eosinophilia without hypersensitivity reactions was noted in other maintenance hemodialysis (MHD) subjects at the same institution. This paper describes these observations and the results o f a study of the prevalence and possible associations o f eosinophilia in a larger group o f MHD subjects.

MATERIALS AND METHODS (i) Eosinophil Counts. Eosinophil counts f o r the prevalence studies were done by hematocytometer (1) by a single observer. Counts contributing to the other observations made in this study were

73 Copyright 0 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system. without permission in writing from the publisher.

74

KOY AND CESTERO

performed by the hospital laboratories. Complete blood counts were done every 4-6 weeks on all MHD patients, and total eosinophil counts were also ordered for confirmation of eosinophilia. Counts were ordered more frequently when the course of eosinophilia was being followed in individual patients. coagulated blood.

All counts were done on EDTA-anti-

Specimens were drawn from all MHD patients before

dialysis except for the section of the study described in Results ( V ) . Eosinophil counts greater than 400 per cubic millimeter (mm5) of Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

blood were considered elevated ( 2 ) .

I n the comparative prevalence

studies a subject was characterized as having eosinophilia if one or both of his eosinophil counts were elevated.

I n the retrospective

chart review a subject was characterized as having eosinophilia over a given time period if at least half his eosinophil counts over that period were elevated. (ii) Subjects. The prevalence of eosinophilia was studied i n controls, azotemic subjects and two groups of MHD subjects. Two counts, at least two weeks apart, were done on controls and the MHD groups, but only one count was done on azotemic subjects. The control group consisted of 30 normal subjects, 16 females and 14 males, ages 23-76 years, mean age 41.1 years. The azotemic group consisted of 20 patients with chronic renal failure, 12 females and 8 males, ages 21-75 years, mean age 47.5 years. The primary renal disease was hypertension (HBP) in 4, chronic glomerulonephritis (CGN) in 4, diabetes mellitus (DM) in 4, interstitial nephritis in 3 , hereditary nephritis in 1, polycystic kidney disease (PCKD) in 1, obstruction in 2 and unknown in 1. Serum creatinine ranged from 5.1-24.8 milligrams per deciliter (mg/dl) , mean 9.9 mg/dl . The first MHD group (MHD I - HFAK-R) consisted of 55 stable MHD patients dialyzed at Monroe Community Hospital 4-6 hours three times a week with a 1.3 m2 or 2.5 m2 hollow fibre artificial kidney, (HFAK) from Cordis Dow Corp, Miami Lakes, Florida. The dialyzers were distributed packed in 3% formaldehyde and were thoroughly rinsed before use until the effluent was Clinitest negative. The dialyzers were used for the same patient an average of 2.5 times, with interim

EOSINOPHILIA IN MAINTENANCE PATIENTS

75

sterilization with 1 112% formaldehyde solution followed by thorough

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

rinsing as above with deionized water or dialysate. Dialyzer lines were polyvinylchloride (PVC) from Cordis Dow. Machines were sterilized with formaldehyde and Chlorox and rinsed with water. Water for dialysate was treated with a reverse osmosis system (Osmonics) and final deionizer polish. Twenty-three subjects were female and thirty-two were male, ages 18-70 years with a mean of 53.4 years. Time since initiation of MHD ranged from 2 to 60 months, with a mean o f 18.4 months. Mean pre-dialysis serum creatinine was 13.3 k 3.2 mg%. The causes of renal failure were HBP in 16, CGN in 9, rapidly progressive GN (RPGN) in 2, GN due to systemic lupus erythematosis (SLE) in 2 , DM in 13, PCKD in 3, interstitial nephritis in 3 , obstruction in 4, and hereditary nephritis, medullary cystic disease and unknown, on each. All patients received pork intestine heparin (liquaemin sodium in 1% benzylalcohol, Organon Inc., West Orange, N.J.) for systemic anticoagulation during dialysis, and usually no protamine. Albumin (Hyland,Travenol Labs, Costa Mesa, California) was rarely if ever used. All patients received multivitamins, folic acid, ascorbic acid and amphogel and many received one or more of the following drugs-digoxin, hydralazine, aldomet, propranolol, antipruritics and antihistamines, coumadin, persantin and minor tranquilizers. Some diabetics received insulin. Twenty-five subjects were receiving I.V. Imferon (Merrell National Laboratories, Cincinnati, Ohio) every two weeks recently prior to or at the time of study. Patients were transfused with washed frozen packed red cells when symptomatic from anemia. The second MHD group (MHD I1 - coils) consisted of thirty patients treated at Rochester General Hospital who were dialyzed two or three times a week exclusively on ethylene-oxide (EO) sterilized EX03 or EX29 coils without reuse (Extracorporeal Medical Specialties, King of Prussia, Pennsylvania). Dialyzer lines were PVC from Dow and Extracorpreal. Dialysate was obtained from the municipal water supply by processing through a continental deionizer. Machines were washed with a dilute solution of Chlorox and rinsed with water between uses. Fifteen patients were male and fifteen female. Ages ranged from 1769 years, with a mean age of 5 2 . 1 years and a median age of 5 . 2 years.

HOY AND CESTERO

76

Time since initiation of dialysis was 2-96 months, with a mean of Mean predialysis serum creatinine was 14.3

2 3 . 2 months.

k 3.2

mg%.

The causes o f renal failure were HBP in 3 , CGN in 7 , RPGN in 1, DM in 4, calculi infection and obstruction in 5, PCKD in 6 , hereditary nephritis in 1, renal malignancy in 1 and unknown in 2. Medications did not differ from those of MHD I except that fewer patients received I.V. Imferon, and plasma protein fraction (Cutter Laboratories Inc. Berkeley, California) was used instead of albumin when needed Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

(rarely).

Washed frozen packed red cells were used for transfusion.

The development of eosinophilia was studied by a retrospective review of the routine 4-6 weekly blood counts of MHD patients treated at Strong Memorial Hospital and Monroe Community Hospital up until June, 1976.

Patients with incomplete charts and those with primary

hematological disorders, malignancies and those receiving cytotoxic agents and corticosteroids were excluded. One hundred and nineteen patients were finally included in the review, however, eosinophil counts prior to initiation of hemodialysis were available in only 68 patients, and information for certain time periods was incomplete in some subjects. The relationships of eosinophilia to Imferon administration, splenectomy, collagen vascular disease, primary renal disease, and dialyzer types, methods of sterilization and the practice of reuse were studied, RESULTS

(i) Systemic hypersensitivity reactions during dialysis in a subject with marked eosinophilia. Figure I shows the course of events in a 29 year old white male with chronic glomerulonephritis who did not have eosinophilia prior to initiation of MHD.

He had a history

of allergy to sulfonamides, characterized by conjunctival injection and facial swelling. During three years of uneventful dialysis he developed progressively higher eosinophil counts, which disappeared during prednisone therapy for two unsuccessful renal transplants, (which were both removed), and recurred when prednisone was discontinued. Hypersensitivity reactions then began to occur during the

77

EOSINOPHILIA IN MAINTENANCE PATIENTS

40,000

30,000

0

2 20,000 al 0

E

l0,OOO

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

E

.

2 2

8,000

6,000

0 0)

2

4,000 2,000

C G.F.

12

24

36

48

60

MONTHS ON HEMODIALYSIS

FIGURE I

The association of eosinophilia with systemic allergic reactions occurring during dialysis and their relationship to the dialyzer. first few minutes of each dialysis,manifest initially by hypotension which was unresponsive to volume replacement, then by accompanying conjunctival injection and burning, nasal congestion and rhinorrhea, circumoral paresthesias and finally facial swelling, chills and temperature (102-103OF), vomiting and diarrhea, dyspnea, bronchospasm and cyanosis. The dyspnea and cyanosis were unresponsive to epinephrine, poorly responsive to benadryl and were terminated only by premature cessation of dialysis. These phenomena did not recur when the patient was switched from an HFAK with reuse with interim formaldehyde sterilization t o EO-sterilized dialyzers without reuse, and there was a dramatic fall in predialysis eosinophil counts, though these have never reached normal levels in the subsequent four years.

HOY AND CESTFXO

78

Another patient with no previous allergic history acquired eosinophilia after 11 months of MHD on HFAK-R and began to have similar but less dramatic symptoms during the early part of the dialysis procedure, but he was transplanted before a change in dialyzer was made. (ii) Documentation of eosinophilia in a large group of MHD patients. Table I shows that the mean percent and total eosinophil counts of MHD I subjects were significantly higher than those of Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

controls and azotemic subjects,and that the percentage of subjects with eosinophilia as previously defined was higher than in controls. In contrast there was no significant difference in any of these values between MHD I1 subjects and controls. When subjects in MHD I who had undergone splenectomy, who had histories of malignancies or who had "collagen vascular" diseases, all of which may be associated with eosinophilia (3), were excluded,the prevalence of eosinophilia in the remainder was 34.8%. The primary renal disease in subjects with eosinophilia was HBP in 5, CGN in 4, RPGN in 2 , DM in 4, interstitial nephritis in 2, obstruction and infection in 2, and SLE and medullary cystic disease in one. Thus there was little association of eosinophilia with any particular disease category. Imferon could not be identified as the cause of eosinophilia, which occurred in 39.1% of 25 subjects receiving the drug, and in 37.5% of 30 subjects not receiving the drug. There was no obvious association of eosinophilia with any other medication. (iii)

Documentation of eosinophilia in MHD I by bone marrow 48 MHD I patients

studies. Bone marrow examinations were performed on (chiefly to assess iron stores).

These showed a moderate to marked

increase in eosinophils and often eosinophilic myelocytes and metamyelocytes in 16 subjects (33.3%).

This incidence correlates well

with that of peripheral eosinophilia. Patients with marked and persistent peripheral eosinophilia showed the most pronounced bone marrow eosinophilia, but bone marrow eosinophilia was quite marked in some patients with only mildly and intermittently elevated peripheral eosinophil counts.

F

?

I

M

m

I

Ln 0

M

M

0

4

a c,

cd r .

N M

r.

d;

0

0

Ln

tu

x

4 rl

N

r(

r.

F

Ln

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

9

0 II

!n

9

W Q ) M +I d

r.

r. Ln

m

rd

5”

P

a

+ m

M

d

rl 4

d

In

+I 0

M

I

u3

I

0

4

0

0

b

‘0,

4

UY

M

M

u3

r. +I Ln

m

I

0

M

c,

cd

m

UY

+I

Ln

m

hl

I

N

0

UY

m

rs tu

x

M

4

n no, M

U

+I

5

!id

0

d

N

M

N N

+I

In

l-4

0

I

0

M

0

t

+I

4 rl

UY

4

I

0

M

Q,

Eh

d

N

+I

M

N

r.

I

0

d

Ln

0

N

+I

4 4

4

M

I

0

M

a

+

8

4

0 k c,

c

0

u

4 Q)

u 0

c,

W Q )

M

5 5&

+I

P

0

m

b 4

m

v)

M 4

4

+I

4

+I hl 0 d

r. r.

UY

UY

4

d

0 0 I

0 0

4

“: M

Ln

r.

UY u3

r.

N

N I

r.

Ln

r .

M

ln

rl rl

0

+I

u3

4

-d k

+I

r.

Ln 0

v, N

4

u3

M

r.

3

N

4

In

Ln

u3 u3

0

F c,

.d

0

al

; 0

U

c, X

a

c,

E:

E

N

4

0 M

N

v)

4

2 b

z

0 U

0

N

N

Ln

0

Ln

M

.?I

3

HOY AND CESTERO

80

(iv) The development of eosinophilia in our MHD population. Figure 2 is assembled from data from the retrospective chart review

.

on 119 subjects and shows the increasing prevalence of eosinophilia with increasing time on dialysis.

Incomplete data indicate that patients

destined to have eosinophilia on MHD had a prevalence of eosinophilia of 22.7% prior to the initiation of hemodialysis, in contrast to a preva-

lence of 13.6% for the entire MHD group prior to dialysis and of 16.7% for controls. Eosinophilia, once evident in an individual, was someRen Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

times intermittent, but did not necessarily show seasonal variation, and rarely disappeared.

In two subjects pre-existing eosinophilia

became more marked on dicloxacillin.

Imferon could not be incriminated

because 84.8% of patients with eosinophilia never received Imferon o r were started on Imferon after eosinophilia had developed. Nor did splenectomy have a major etiological role as 8 3 . 3 % of subjects with eosinophilia did not undergo splenectomy or had the procedure after eosinophilia had developed. There appeared to be little relationship between eosinophilia and the nature of the primary renal disease. (v)

Eosinophil counts during dialysis. In 13 subjects, six of

whom had eosinophilia, white cell counts and differentials and total eosinophil counts were done on blood samples collected predialysis and at 10 and 30 minutes, and 1, 4, and 6 hours into dialysis. Eosinophil counts were markedly lower at 10 and sometimes 30 minutes coincident with the drop in total white cell count attributed to "dialysisinduced leukopenia" ( 4 ) , butarose again to a level below o r equal to, but not exceeding, the predialysis count. (vi) Eosinophilia and the dialyzer. Two facts suggest that eosinophilia may be related to formaldehyde or dialyzer reuse, or both. (a) In three MHD I subjects examined prospectively total eosinophil counts fell coincident with a change in dialyzer. The patient whose course is shown in Figure 1 has already been discussed. Figures 3 and 4 show increasing eosinophilia in two subjects while being

dialyzed on formaldehyde-sterilized HFAK with reuse,and a fall in eosinophil counts after change to EO-sterilized Paraflo dialyzers without reuse (Travenol Labs, Deerfield, Illinois).

In neither case,

81

EOSINOPHILIA LN MAINTENANCE PATIENTS

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

t --4

I

0 k-WEEKS

6

12

24

12

4-

1

I

I

24

36

48

I

60

MONTHS

TIME AFTER INITIATION OF HEMODIALYSIS FIGURE I1

Increasing prevalence of eosinophilia in a group of patients with increasing time on hemodialysis.

however, was eosinophilia abolished. Subject SB died in a motor accidentninemonths after the change, so further follow-up was not possible; subject JS has maintained an intermittent eosinophilia for thirty months since the switch but never of the magnitude prior to the switch and without seasonal variation. (b) Neither the mean eosinophil count nor the prevalence Of eosinophilia in MHD I 1 was significantly greater than in controls. One of the few clear differences between these subjects and MHD I was

.

dialysis with single use EO-sterilized coils in the former group and formaldehyde-sterilizedHFAK with reuse in the latter group. Three facts indicate, however, that formaldehyde and/or reuse are not the sole or even the most common sensitizing agents. (a) Thirteen patients included in the retrospective chart review acquired o r maintained eosionphilia after at least three months' treatment with dialyzers other than the formaldehyde-sterilized HFAK-R, including EX coils and Paraflo and Gambro (Gambro Inc. Chicago, Illinois) parallel plate dialyzers (EO-sterilized, no reuse). Eosinophilia in this group was, therefore, not exclusively related to the use of HFAK with or without reuse.

KOY AND CESTERO

82

6PARAFLO-NR -

DOW HFAK-R-

2000 1800 0

Q

1600

0

2 1400 Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

$

1200

2- ‘Oo0 1

$

I

t

800

0

2

* . 600

’%

*t

2 400 * . *.re.

200

0 S.B.

I

1

6

12

18

24

26

28

30

32

MONTHS ON HEMODIALYSIS FIGURE I11

Course of e o s i n o p h i l i a i n p a t i e n t SB. (b)

F i f t y - n i n e p a t i e n t s included i n t h e r e t r o s p e c t i v e c h a r t

review were dialyzed e x c l u s i v e l y with HFAK-R with formaldehyde s t e r i l i z a t i o n f o r a t l e a s t 1 2 months.

The prevalence of e o s i n o p h i l i a

between 7 and 1 2 months i n t h e s e s u b j e c t s was 22%, a f i g u r e not s i g n i f i c a n t l y d i f f e r e n t from t h a t of t h e e n t i r e group a t 7-12 months (23.5%). (c) T h i r t y - s i x p a t i e n t s from MHD I were switched from HFAK-R t o HFAK without reuse (HFAK-NR). Two eosinophil counts a t l e a s t two weeks a p a r t were done before t h e change when e o s i n o p h i l i a was d e t e c t e d i n 1 2 s u b j e c t s (33.3%). Two counts on each s u b j e c t a f t e r a t l e a s t 2 months’ d i a l y s i s with HFAK-NR revealed e o s i n o p h i l i a i n 9 s u b j e c t s (25%),

EOSINOPHILIA IN MAINTENANCE PATIENTS

83

-

DOW H F A K - R p -PARAFLO-NR

2400

.

2200 2000 Q

1800

0

2ul 1600

c *

:

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

0

I4O0

**

\

VJ 1200

E!

30 1000 2

aoo

0

.

L' 600

. e

400

.

*

* *

.* * *

.

.

200 0 2 4 6 8 10 16

J.S.

'8

20

22

24

26

28

30

32

34

MONTHS ON HEMODIALYSIS

FIGURE IV Course of eosinophilia in patient JS.

6 patients having maintained, 6 having lost and 3 having acquired

eosinophilia over that period. There was no significant change in the mean eosinophil count. DISCUSSION In this study eosinophilia of peripheral blood and bone marrow was found in about one third of a group of MHD patients dialyzed with formaldehyde-sterilized reused hollow fibre artifical kidneys. The prevalence of peripheral eosinophilia was significantly greater than that in azotemic subjects and controls. This phenomenon is not

84

HOY AM) CESTERO

confined to our unit, for a recent bone marrow study on 55 MHD subjects revealed an increased mean eosinophil count when compared with controls; the bone marrows of 9 undialyzed azotemic subjects also showed a higher mean eosinophil count than controls, but the difference was not of statistical significance (5).

I n that report, however, the propor-

tion of MHD sujbects who had bone marrow eosoniphilia was not stated, and the peripheral blood picture was not described. The prevalence of eosinophilia in our MHD population rose with Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

increasing time on dialysis.

In individual patients eosinophilia,

once established, was sometimes intermittent o r o f variable magnitude, without obvious seasonal variation, but did not usually permanently resolve. Patients with eosinophilia on MHD had a higher incidence of at least intermittent eosinophila before the initiation of hernodialysis than other MHD patients and controls. Some, but not all, had histories of atopy, with rhinitis, eczema, o r drug allergies. No consistent association with any particular primary renal disease, any systemic disease, o r with splenectomy o r a single drug was obvious. The fall in eosinophil counts in 3 patients that followed a change from formaldehyde-sterilizedHFAK-R to EO-sterilized dialyzers without reuse suggests that hypersensitivity in these subjects had some relationship to formaldehyde exposure, the practice of reuse, o r both. A much less intense eosinophilia persisted subsequently in all 3 patients suggesting that they continued to be exposed to a lesser

dose of the prior sensitizing agent, o r that they had multiple sensitivities, only one factor having been eliminated by the change in dialyzer. The apparent lack of eosinophilia in a group of MHD patients at another center, who seemed well matched with our MHD I group except f o r the fact that they were dialyzed exclusively on EO-sterilized coils

without reuse, also seems to suggest that eosinophilia in our patients is related either to formaldehyde o r reuse. However, several pieces of evidence do not favor these factors as the sole o r even the chief cause of eosinophilia. First, the retrospective chart review showed that eosinophilia amongst our patients was not limited to those dialyzed

EOSINOPHILLA IN MAINTENANCE PATIENTS only with formaldehyde-sterilized HFAK.

85

Second, eosinophilia has con-

tinued to appear in subjects followed prospectively, who have been started on MHD since this study was concluded, many of whom have been dialyzed only with EO-sterilized parallel plate dialyzers. Third, the MHD group with bone marrow eosinophilia described by Sjggren and Thysell (5) were dialyzed only with EO-sterilized Gambro Lundia Nova dialyzers. Fourth, our cross-over trial failed to implicate reuse

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

as a significant cause of eosinophilia in the 36 W D I subjects studied. However, the duration of dialysis without reuse in some cases was short ( 2 months), and more important, several patients from MHD I with the

most intense eosinophilia were not included in the trial because they had been switched to dialysis on EO-sterilized equipment without reuse before the cross-over study was undertaken. Hemodialysis patients are exposed to a multitude of substances which may be toxic (6), or invoke hypersensitivity. Oral drugs, intravenous medications containing stabilizers and preservatives, blood products, chelating agents in transfused blood, traces of chemicals such as formaldehyde and ethylene oxide, plasticizers from tubing or bags of intravenous fluids, particles of plastic, spicules of glass from drug vials and even particles of rubber from stoppers of multiple dose vials are just a few potential hazards. Ethylene oxide from EOsterilized equipment can cause systemic allergic reactions ( 7 ) , thiouram leached from rubber has caused allergic contact sensitivity in a group of MHD subjects (8), and heparin can cause eosinophilia (9). Anaphylactoid reactions due to non-immune complex serum protein aggregates have been described

(lo), and a model for this may exist in

MHD patients exposed to reinfusion of plasma proteins altered after

adherence to and aggregation on the dialyzer membrane (11).

The

presence of circulating free DNA during dialysis ( 1 2 ) , and the increased prevalence of antinuclear antibody in MMD patients ( 1 3 ) attest to reinfusion of and sensitization to nuclear material as a result of white cell disruption on the membrane (11).

Formaldehyde

reacts with and alters amino acids, proteins, nucleic acids, nucleosides, nucleotides and nucleoproteins (14), and red cell membranes (15),

HOY AND CESTERO

86

rendering them more antigenic. These and other agents could all cause sensitization, especially in patients with an atopic diathesis, and perhaps it is surprising that eosinophilia is not more prevalent in this population. The association of eosinophilia with severe hypersensitivity reactions during dialysis in two patients indicates that this problem may be of more than academic interest.

Its possible relation to

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

unexplained pulmonary infiltrates, abnormal liver enzymes and even hemolytic anemia is being investigated. The purpose of the present communications is to encourage other centers to report their experience with this phenomenon and thereby perhaps more closely pinpoint it causes. REFERENCES 1.

John B. Miale, Laboratory Medicine-Hematology, 3rd Ed., p. 1126, C.V. Mosby Co. St. Louis, 1967.

2.

Ibid, p. 834.

3. Ibid, p . 834. 4. Kaplow, L. S. and Goffinet, J. A., J. Am. Med. ASSOC., 203: 1135, 1968. 5. Sjogren, U. and Thysell, H., Acta. Haemat.

E:

332, 1977.

6. Alfrey, A. C., et al., Trans. Am. SOC. Artif. Intern. Organs XXIV: 764, 1978. 7.

Poothullil, J., Shimizu, A., Day, R. P., and Dolovich, J., Annals Intern. Med. g : 58, 1975.

8.

Penneys, N. S., Edwards, L. S. and Katsikas, J. L., Arch. Dermatol 112: 811, 1976.

9.

Barr, S. E., Brown, H. and Dyer, R. F., J. Allergy

10.

31:

406, 1960.

Ring, J., Seifert, J., Jesch, F., and Brendel, W., Monogr. Allergy 12: 27, 1977. -

11. Marshall, J. W . , Ahearn, D. J., Nothum, R. J., Esterly, J., Nolph, K. D., Maher, J. F., Nephron 12: 157, 1974. 12.

Steinman, C. R, Ackad, A . , Am. J. Med.

62:

693, 1977.

87

EOSINOPHUIA IN MAINTENANCE PATIENTS

13. Nolph, K . D., Husted, F. C., Sharp, G. Am. J . Med. 60: 673, 1976.

C.,

and Siemsen, A. W.,

14. Auerbach, C., Moutschen-Dahmen, M., and Moutschen, J . , Mutation Research 2: 317, 1977. 15. Koch, K. M., Frei, U., and Fassbinder, W., Trans. 709, 1978. Intern. Organs E:

Am. SOC.

Artif.

Ren Fail Downloaded from informahealthcare.com by Nyu Medical Center on 01/07/15 For personal use only.

ACKNOWLEDGMENTS We offer special thanks to Dr. Kong-oo Goh for performing the bone marrow studies and M s . Ellen Yatteau for typing the manuscript.

Eosinophilia in maintenance hemodialysis patients.

JOURNAL OF DIALYSIS, 3(1), 73-87 (1979) EOSINOPHILIA IN MAINTENANCE HEMODIALYSIS PATIENTS Ren Fail Downloaded from informahealthcare.com by Nyu Medi...
624KB Sizes 0 Downloads 0 Views