Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets

[Acute pancreatitis as a complication of massive hemolysis in patients on hemodialysis: About three observations]

Haemolysis is an uncommon complication of haemodialysis which can be serious. We herein report on three patients with kidney failure who developed acute pancreatitis due to mechanical haemolysis during a haemodialysis session. We also review the current literature and discuss putative etiopathogenic mechanisms.

Apple intake improves antioxidant parameters in hemodialysis patients without affecting serum potassium levels

Oxidative stress (OS) is associated with increased morbidity and mortality in hemodialysis (HD) patients, and the consumption of fruits seems to improve OS due to their antioxidant properties. Therefore, we hypothesized that Fuji apple intake improves OS markers in HD patients due to its polyphenolic compounds without increasing serum potassium levels. This trial was a 1-group, pre- and posttest comparison between 16 patients who had been on hemodialysis for at least 3 months without any acute illness or hyperkalemia. Each volunteer consumed 2 Fuji apples (~360 g) per day for 1 week. Blood samples were collected at the baseline period and after 8 days for the measurement of total antioxidant status, ascorbic acid, catalase, glutathione peroxidase, superoxide dismutase, reduced glutathione, total oxidant status, oxidative stress index, potassium, phosphorus, uric acid, glucose, and fructosamine. For tolerance evaluation, participants were asked about their bowel habits. Apple intake increased glutathione peroxidase (P = .006) and superoxide dismutase activities (P = .006) and ascorbic acid levels (P = .002). No significant changes were observed in uric acid, potassium, phosphorus, glucose, and fructosamine levels. Additionally, there was a decrease in the catalase activity (P = .021) and in the total antioxidant status values (P = .004). However, increased total oxidant status (P = .003) and oxidative stress index (P = .033) levels were observed after apple intake. In conclusion, the intake of 2 Fuji apples per day for 1 week was well tolerated and improved antioxidant parameters in HD patients without affecting serum potassium levels.

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

Given the high comorbidity in patients on hemodialysis and the complexity of the dialysis treatment, it is remarkable how rarely a life-threatening complication occurs during dialysis. The low rate of dialysis emergencies can be attributed to numerous safety features in modern dialysis machines; meticulous treatment and testing of the dialysate solution to prevent exposure to trace elements, toxins, and pathogens; adherence to detailed treatment protocols; and extensive training of dialysis staff to handle medical emergencies. Most hemodialysis emergencies can be attributed to human error. A smaller number are due to rare idiosyncratic reactions. In this review, we highlight major emergencies that may occur during hemodialysis treatments, describe their pathogenesis, offer measures to minimize them, and provide specific interventions to prevent catastrophic consequences on the rare occasions when such emergencies arise. These emergencies include dialysis disequilibrium syndrome, venous air embolism, hemolysis, venous needle dislodgement, vascular access hemorrhage, major allergic reactions to the dialyzer or treatment medications, and disruption or contamination of the dialysis water system. Finally, we describe root cause analysis after a dialysis emergency has occurred to prevent a future recurrence.

Unexpected triggering of the dialysate blood leak detector by haemolysis

This case showed that it is possible for haemoglobin released by haemolysis in the extracorporeal circuit to pass through a high permeability (albumin retaining) dialyser membrane. In the incident described, the blood leak detector of the dialysis machine was activated before the patient became symptomatic. Haemolysis should be considered as a possible cause of blood leak alarms during dialysis with high flux membranes.

In Vitro Comparative Assessment of Mechanical Blood Damage Induced by Different Hemodialysis Treatments

Gradual deterioration of red blood cells (RBCs) due to mechanical stress (chronic hemolysis) is unavoidable during treatments that involve extracorporeal blood circulation, such as hemodialysis (HD). This effect is generally undetectable and does not generate any acute symptoms, but it leads to an increase in plasma free hemoglobin (fHb). There are no absolute safety levels for fHb increase, indicating the need for an empirical evaluation using comparative testing. The increase in fHb levels was investigated in vitro by applying double‐needle double‐pump HD (HD‐DNDP), a new modality in which arterial and venous pumps both run continuously. fHb was measured during typical and worst‐case simulated dialysis treatments (double‐needle single‐pump HD [HD‐DNSP], hemodiafiltration [HDF‐DN], single‐needle double‐pump HD [HD‐SNDP], and HD‐DNDP) performed in vitro using bovine blood for 4 h. Hemolysis‐related indices (fHb%; index of hemolysis, IH; and normalized IH) were calculated and used for comparison. The increase in fHb during either HDF‐DN or HD‐SNDP with Artis and AK200 dialysis machines was similar, while the fHb at the maximum real blood flow rate (Qb_real) at the completion of the HD‐DNDP treatment on Artis was higher than that for HD‐DNSP using a Phoenix dialysis machine (fHb% = 1.24 ± 0.13 and 0.92 ± 0.12 for the Artis machine with HD‐DNDP at Qb_real = 450 mL/min and Phoenix with HD‐DNSP at Qb_real = 500 mL/min, respectively). However, the fHb levels increased linearly, and no steep changes were observed. The increases observed during HD‐DNDP were the same order of magnitude as those for widely used bloodlines and treatment modes for delivering dialysis treatments. The observed results matched literature findings, and thus the measured fHb trends are not predicted to have clinical side effects. HD‐DNDP treatment with Artis does not merit any additional concern regarding mechanical stress to RBCs compared with that observed for routinely used dialysis treatments, bloodlines and machines. Although the in vitro measurement of the fHb increase in bovine blood does not allow a prediction of the absolute level of blood mechanical damage or the possible effects in humans, such measurements are valuable for assessing hemolytic harm by performing tests comparing the proposed treatment with existing devices.

Hemolysis as a rare but potentially life-threatening complication of hemodialysis: a case report

BACKGROUND

The burden of end-stage renal disease (ESRD) in the United States has increased dramatically over the past 30 years with almost 613,000 patients receiving renal replacement therapy in 2011. That same year, more than 112,000 new patients initiated dialysis with 92% of them receiving hemodialysis (HD). These patients experience significant morbidity and mortality with very frequent emergency room visits. Acute hemolysis associated with HD is a rare complication; however, if it's not recognized early and managed adequately, it can be associated with life-threatening complications such as hyperkalemia and even myocardial infarction.

CASE PRESENTATION

66-year-old African-American female with a history of ESRD secondary to hypertension developed a blood infiltration on the arterial side of her arteriovenous fistula followed by sudden onset of diffuse abdominal pain with nausea and vomiting during her regular HD treatment. She was referred to the emergency department where she was found to have shortness of breath with improved gastrointestinal symptoms. Her initial work-up revealed a severe anemia with a hematocrit of 10%. Further work-up revealed massive hemolysis, likely mechanical in nature and believed to be induced by malpositioning of her HD needle in the fistula. Her hospital course was complicated by rhabdomyolysis and acute myocardial infarction thought to be secondary to supply-demand ischemia in the setting of her profound anemia. Within a week, she eventually had a full recovery.

CONCLUSION

It is extremely important for physicians and particularly emergency department physicians to be aware of this potentially life-threatening complication of HD and have a high index of suspicion in the setting of acute anemia with hemolysis in this population.

Performance characteristics of a novel blood bag in-line closure device and subsequent product quality assessment

BACKGROUND

In high-volume processing environments, manual breakage of in-line closures can result in repetitive strain injury (RSI). Furthermore, these closures may be incorrectly opened causing shear-induced hemolysis. To overcome the variability of in-line closure use and minimize RSI, Fresenius Kabi developed a new in-line closure, the CompoFlow, with mechanical openers.

STUDY DESIGN AND METHODS

The consistency of the performance of the CompoFlow closure device was assessed, as was its effect on component quality. A total of 188 RBC units using CompoFlow blood bag systems and 43 using the standard bag systems were produced using the buffy coat manufacturing method. Twenty-six CompoFlow platelet (PLT) concentrates and 10 control concentrates were prepared from pools of four buffy coats. RBCs were assessed on Days 1, 21, and 42 for cellular variables and hemolysis. PLTs were assessed on Days 1, 3, and 7 for morphology, CD62P expression, glucose, lactate, and pH. A total of 308 closures were excised after processing and the apertures were measured using digital image analysis.

RESULTS

The use of the CompoFlow device significantly improved the mean extraction time with 0.46 ± 0.11 sec/mL for the CompoFlow units and 0.52 ± 0.13 sec/mL for the control units. The CompoFlow closures showed a highly reproducible aperture after opening (coefficient of variation, 15%) and the device always remained opened. PLT and RBC products showed acceptable storage variables with no differences between CompoFlow and control.

CONCLUSIONS

The CompoFlow closure devices improved the level of process control and processing time of blood component production with no negative effects on product quality.