Hypersensitivity reactions to ethylene oxide (EtO) sterilized dialyzers have been well described. While EtO is no longer used to sterilize most dialyzers, it is used on other pieces of dialysis equipment. We present a case of a 78-year-old male who suffered dialysis-related anaphylaxis attributed to an IgE-mediated allergy to EtO-sterilized dialysis tubing and needles. Shortly after transitioning from a tunneled catheter to an arteriovenous fistula, he developed multiple episodes of intradialytic hypotension and syncope within minutes of starting dialysis. Laboratory evaluation revealed marked leukocytosis, eosinophilia and elevated anti-EtO IgE antibody. Following pre-treatment with corticosteroids and antihistamines, rinsing of dialysis tubing, and transition of access back to a tunneled catheter, he tolerated subsequent dialysis treatments. Review of his history revealed chronic eosinophilia since the time of hemodialysis initiation. We hypothesize his eosinophilia and mast cell degranulation began upon initial exposure to EtO and hemodialysis equipment. When use of the arteriovenous fistula was resumed, he was exposed to a higher "dose" of EtO due to use of needles. The higher antigenic stimuli triggered memory immune response leading to mast cell degranulation and repeated anaphylactic episodes that were overcome by minimization of EtO sterilized equipment, corticosteroid pretreatment and the anti-IgE Fc monoclonal, omalizumab.