Journal of Dialysis
ISSN: 0362-8558 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/irnf17
Acute Hemolysis Due to Profound HypoOsmolality. A Complication of Hemodialysis R. Said, A. Quintanilla, N. Levin & P. Ivanovich To cite this article: R. Said, A. Quintanilla, N. Levin & P. Ivanovich (1977) Acute Hemolysis Due to Profound Hypo-Osmolality. A Complication of Hemodialysis, Journal of Dialysis, 1:5, 447-452, DOI: 10.3109/08860227709082380 To link to this article: http://dx.doi.org/10.3109/08860227709082380
Published online: 07 Jul 2009.
Submit your article to this journal
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Date: 20 April 2016, At: 07:20
JOURNAL OF DIALYSIS, 1 ( 5 ) , 447-452 (1977)
Downloaded by [RMIT University Library] at 07:20 20 April 2016
ACUTE HEMOLYSIS DUE TO PROFOUND HYPO-OSMOLALITY. A COMPLICATION OF HFMODIALYSIS
R. Said, A. Q u i n t a n i l l a , N. Levin, and P. Ivanovich Section of Nephrology/Hypertension, Department of Medicine Northwestern University-McGaw Medical Center, Chicago, I L 60611 ABSTRACT
Acute hemolysis i n maintenance hemodialysis p a t i e n t s is n o t a rare occurrence. S i g n i f i c a n t hemolysis i s l i f e - t h r e a t e n i n g and may be unrecognized because of nonepecif i c symptomatology This paper r e p o r t s observation of a severe hemolytic episode i n a hemodialysis p a t i e n t . The hemolysis w a s a s s o c i a t e d with a sudden drop i n serum osmolality and profound hyponatremia, r e s u l t i n g from a c c i d e n t a l d i a l y s i s a g a i n s t deionized water. Recognizing t h e condition and t r e a t i n g i t promptly by d i a l y s i s with physiological d i a l y s a t e are essential f o r patient survival.
.
The following r e p o r t illustrates a case of severe hemolysis r e s u l t i n g from a period of hemodialysis a g a i n s t deionized water. CASE PRESENTATION
J.B.,
a 48-year o l d white male p a t i e n t , had a long h i s t o r y of
chronic glomerulonephrltis, terminating i n severe r e n a l i n s u f f i c i e n c y and hypertension.
He w a s s t a r t e d on maintenance hemodialysis i n
December, 1970 and t r e a t e d with twice weekly d i a l y s e s of 12 hours with standard K i i l d i a l y z e r .
I n April, 1971 a b i l a t e r a l nephrectomy
w a s performed f o r c o n t r o l of s e v e r e hypertension.
447 Copyright @ 1977 hy Marcel Dekker. Inc. All Rights Reserved. Nrilhrr this work nor any part may be reproduced or transmitted in any form or by any meahs. electronic or mechanical. including photocopying, microfilming, and recording, or by any information storage and retrieval system. without permission in writing from the publisher.
448
ET .ac
SATD
Near t h e t e r m i n a t i o n of one of h i s d i a l y s e s he devef..?ned s e v e r e cramping abdominal p a i n s w i t h l o o s e bowel movements.
He
complained of muscle spasms i n h i s l e g s , became a p p r e h e n s i v e and incoherent.
Because t h e symptoms worsened w i t h d i a l y s i s , t h e
c h a r g e n u r s e w a s a d v i s e d by a p h y s i c i a n t o remove t h e p a t i e n t f r o m
Downloaded by [RMIT University Library] at 07:20 20 April 2016
hemodialysis.
H e r e c o m e n d e d t h i s a c t i o n d e s p i t e a normal r e a d i n g
of t h e d i a l y s a t e d e l i v e r y s y s t e m ' s c o n d u c t i v i t y meter.
On examination t h e p a t i e n t w a s comatose, responding o n l y t o painful stimuli.
His blood p r e s s u r e w a s 240/130 mmHg; he was
b r e a t h i n g r a p i d l y and d e e p l y w i t h Kussmal-like r e s p i r a t i o n s .
were no l o c a l i z i n g n e u r o l o g i c f i n d i n g s .
There
Laboratory s t u d i e s
r e v e a l e d a h e m a t o c r i t of 8 ( p r e - d i a l y s i s 2 0 ) .
The plasma w a s
r e d d i s h i n c o l o r w i t h a hemoglobin c o n c e n t r a t i o n of 950 mg/100 m l (Figure 1).
T h i s plasma had a sodium v a l u e of 105 mEq/L, c h l o r i d e
75 mEq/L, potassium 4.7 mEqfL, and C02 9.5 mEa/L, u r e a n i t r o g e n 25 mg/100 m l , g l u c o s e 300 mg/100 m l .
Its o s m o l a l i t y w a s
240 mosml/L ( T a b l e I ) , The p a t i e n t ' s e l e v a t e d blood p r e s s u r e was c o n t r o l l e d by parencerally administered hydralazine.
H e was g i v e n 500 m l 3%
sodium c h l o r i d e i n t r a v e n o u s l y and d i a l y s i s w a s resumed u s i n g two
1,3 m 2 hollow- f i b e r d i a l y z e r s connected i n series. W i t h i n one h a l f - h o u r a f t e r t h e resumption of d i a l y s i s , t h e p a t i e n t began t o respond t o q u e s t i o n i n g a l t h o u g h h e ramained somnolent and confused for a f u r t h e r half-hour.
After four hours
ef d i a l y s i s , t h e p a t i e n t w a s c o n v e r s i n g n o r m a l l y and was a b l e to s t a n d eo b e weighed a t t h e end of t i e a t m e n t .
Downloaded by [RMIT University Library] at 07:20 20 April 2016
ACUTE IIEMMOLY S LS
449
0
100
1 I
0 0 0 I
I
I
I
I
12.00
2.00
4.00
12.00
4.00
I
2nd day
1
I
3rd day
4th day
FIGURE 1 Plasma Hemoglobin Concentration
DISCUSS ION
During d i a l y s i s t h e audio and v i s u a l alarms of t h e p a t i e n t ' s propartioning delivery system were a c t i v a t e d and d i a l y s a t e waa bypassing t h e hemodialyzer.
The alarms were a c t i v a t e d because t h e
conductivity meter's lower limit was exceeded as t h e hemodialysis concentrate tank had emptied.
A s t a f f member i n attendance,
SAID ET AL.
450 TABLE I PRE-DIALYSIS AND POST-HEMOLYSIS CHEMISTRIES
+
C1
co
mEq/L
mEq3L
Hct
dq/L
135
5.0
90
16.0
20
320
a0
104
4.7
76
9.5
a
250
25
u : 3 0 AM
iia
3. a
75
10.0
12
270
2:30 AM
120
3.0
74
10.8
ia
270
6:OO AM
126
3.1
a0
13.0
ia
278
P redialysis
Downloaded by [RMIT University Library] at 07:20 20 April 2016
k
Na mEq/L
Osm. mosml/L
BUN mg/dl
Posthemolysis
9/23 9:30 PM 9124
observing t h e alarms, f a i l e d t o recognize t h e i r cause.
To o v e r r i d e
t h e alarm he recentered t h e c o n d u c t i v i t y meter p l a c i n g t h e machine i n a s a f e o p e r a t i n g mode, and allowing deionized water t o be pumped through t h e hemodialyzer. a c t i o n s he l e f t t h e d i a l y s i s area.
Without n o t i f y i n g anyone of his Shortly thereafter the patient
became ill. The hemolytic episode which followed occurred as a r e s u l t of osmolar i n j u r y t o RBCs w i t h profound hyponatremia caused by d i a l y z i n g t h e p a t i e n t a g a i n s t deionized water. oemolality dropped suddenly from
The p a t i e n t ' s serum
320 mOsml/L t o 250 mOsml/L with
e x t e n s i v e hemolysis aa evidenced by t h e l e v e l of plasma hemoglobin c o n c e n t r a t i o n and t h e f a l l of hematocrft.
His symptoms w e r e
ACUTE HPi0LYSI.S
451
compatible with t h e p i c t u r e of acute water i n t o x i c a t i o n described by Arieff e t al. (l), and were manifestations of b r a i n edema, r e s u l t i n g i n marked disturbances of consciousness, apprehension, and increased blood pressure.
Downloaded by [RMIT University Library] at 07:20 20 April 2016
The administration of a hypertonic s o l u t i o n of sodium chloride may have been h e l p f u l b u t t h e r e w a s no c l i n i c a l improvement u n t i l t h e p a t i e n t was dialyzed a g a i n s t d i a l y s a t e Na'
130 mEqJL and was transfused.
concentration of
The p a t i e n t ' s symptoms promptly
abated with full c l i n i c a l recovery.
CONCLUSION Suman e r r o r i s most o f t e n t h e cause of d i a l y s i s hemolysis. P a t i e n t s and s t a f f must be constantly r e t r a i n e d to obviate a c c i d e n t a l d i a l y s i s a g a i n s t water. When hemolysis occurs or is suspected i n a p a t i e n t being
dialyzed, t h e treatment should b e stopped and t h e d i a l y s a t e and serum immediately checked f o r sodium concentration.
I f the
d i d y s a t e is hyponatremic, another source of c o r r e c t d i a l y s a t e production must be found i n order t o l i m i t t h e p o s s i b i l i t y of s e r i o u s consequences of acute c e r e b r a l edema.
Promptly dialyzing
t h e hyponatremic p a t i e n t with hemolysis with proper d i a l y s a t e may be l i f e s a v i n g .
SXIIn ET
452
.a.
CHANGE OF ADDRESS
Dr. N . Levin's present address is:
Division of Nephrology Department of Medic;ne Henry Ford Hospital Detroit, M I 48202
Downloaded by [RMIT University Library] at 07:20 20 April 2016
REFERENCE
1.
Allen, I., Arieff, A . , and Guisado, R., Kid. I n t . , g : l W - . i i f i 9 1976.
ISSN: 0362-8558 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/irnf17
Acute Hemolysis Due to Profound HypoOsmolality. A Complication of Hemodialysis R. Said, A. Quintanilla, N. Levin & P. Ivanovich To cite this article: R. Said, A. Quintanilla, N. Levin & P. Ivanovich (1977) Acute Hemolysis Due to Profound Hypo-Osmolality. A Complication of Hemodialysis, Journal of Dialysis, 1:5, 447-452, DOI: 10.3109/08860227709082380 To link to this article: http://dx.doi.org/10.3109/08860227709082380
Published online: 07 Jul 2009.
Submit your article to this journal
Article views: 21
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=irnf17 Download by: [RMIT University Library]
Date: 20 April 2016, At: 07:20
JOURNAL OF DIALYSIS, 1 ( 5 ) , 447-452 (1977)
Downloaded by [RMIT University Library] at 07:20 20 April 2016
ACUTE HEMOLYSIS DUE TO PROFOUND HYPO-OSMOLALITY. A COMPLICATION OF HFMODIALYSIS
R. Said, A. Q u i n t a n i l l a , N. Levin, and P. Ivanovich Section of Nephrology/Hypertension, Department of Medicine Northwestern University-McGaw Medical Center, Chicago, I L 60611 ABSTRACT
Acute hemolysis i n maintenance hemodialysis p a t i e n t s is n o t a rare occurrence. S i g n i f i c a n t hemolysis i s l i f e - t h r e a t e n i n g and may be unrecognized because of nonepecif i c symptomatology This paper r e p o r t s observation of a severe hemolytic episode i n a hemodialysis p a t i e n t . The hemolysis w a s a s s o c i a t e d with a sudden drop i n serum osmolality and profound hyponatremia, r e s u l t i n g from a c c i d e n t a l d i a l y s i s a g a i n s t deionized water. Recognizing t h e condition and t r e a t i n g i t promptly by d i a l y s i s with physiological d i a l y s a t e are essential f o r patient survival.
.
The following r e p o r t illustrates a case of severe hemolysis r e s u l t i n g from a period of hemodialysis a g a i n s t deionized water. CASE PRESENTATION
J.B.,
a 48-year o l d white male p a t i e n t , had a long h i s t o r y of
chronic glomerulonephrltis, terminating i n severe r e n a l i n s u f f i c i e n c y and hypertension.
He w a s s t a r t e d on maintenance hemodialysis i n
December, 1970 and t r e a t e d with twice weekly d i a l y s e s of 12 hours with standard K i i l d i a l y z e r .
I n April, 1971 a b i l a t e r a l nephrectomy
w a s performed f o r c o n t r o l of s e v e r e hypertension.
447 Copyright @ 1977 hy Marcel Dekker. Inc. All Rights Reserved. Nrilhrr this work nor any part may be reproduced or transmitted in any form or by any meahs. electronic or mechanical. including photocopying, microfilming, and recording, or by any information storage and retrieval system. without permission in writing from the publisher.
448
ET .ac
SATD
Near t h e t e r m i n a t i o n of one of h i s d i a l y s e s he devef..?ned s e v e r e cramping abdominal p a i n s w i t h l o o s e bowel movements.
He
complained of muscle spasms i n h i s l e g s , became a p p r e h e n s i v e and incoherent.
Because t h e symptoms worsened w i t h d i a l y s i s , t h e
c h a r g e n u r s e w a s a d v i s e d by a p h y s i c i a n t o remove t h e p a t i e n t f r o m
Downloaded by [RMIT University Library] at 07:20 20 April 2016
hemodialysis.
H e r e c o m e n d e d t h i s a c t i o n d e s p i t e a normal r e a d i n g
of t h e d i a l y s a t e d e l i v e r y s y s t e m ' s c o n d u c t i v i t y meter.
On examination t h e p a t i e n t w a s comatose, responding o n l y t o painful stimuli.
His blood p r e s s u r e w a s 240/130 mmHg; he was
b r e a t h i n g r a p i d l y and d e e p l y w i t h Kussmal-like r e s p i r a t i o n s .
were no l o c a l i z i n g n e u r o l o g i c f i n d i n g s .
There
Laboratory s t u d i e s
r e v e a l e d a h e m a t o c r i t of 8 ( p r e - d i a l y s i s 2 0 ) .
The plasma w a s
r e d d i s h i n c o l o r w i t h a hemoglobin c o n c e n t r a t i o n of 950 mg/100 m l (Figure 1).
T h i s plasma had a sodium v a l u e of 105 mEq/L, c h l o r i d e
75 mEq/L, potassium 4.7 mEqfL, and C02 9.5 mEa/L, u r e a n i t r o g e n 25 mg/100 m l , g l u c o s e 300 mg/100 m l .
Its o s m o l a l i t y w a s
240 mosml/L ( T a b l e I ) , The p a t i e n t ' s e l e v a t e d blood p r e s s u r e was c o n t r o l l e d by parencerally administered hydralazine.
H e was g i v e n 500 m l 3%
sodium c h l o r i d e i n t r a v e n o u s l y and d i a l y s i s w a s resumed u s i n g two
1,3 m 2 hollow- f i b e r d i a l y z e r s connected i n series. W i t h i n one h a l f - h o u r a f t e r t h e resumption of d i a l y s i s , t h e p a t i e n t began t o respond t o q u e s t i o n i n g a l t h o u g h h e ramained somnolent and confused for a f u r t h e r half-hour.
After four hours
ef d i a l y s i s , t h e p a t i e n t w a s c o n v e r s i n g n o r m a l l y and was a b l e to s t a n d eo b e weighed a t t h e end of t i e a t m e n t .
Downloaded by [RMIT University Library] at 07:20 20 April 2016
ACUTE IIEMMOLY S LS
449
0
100
1 I
0 0 0 I
I
I
I
I
12.00
2.00
4.00
12.00
4.00
I
2nd day
1
I
3rd day
4th day
FIGURE 1 Plasma Hemoglobin Concentration
DISCUSS ION
During d i a l y s i s t h e audio and v i s u a l alarms of t h e p a t i e n t ' s propartioning delivery system were a c t i v a t e d and d i a l y s a t e waa bypassing t h e hemodialyzer.
The alarms were a c t i v a t e d because t h e
conductivity meter's lower limit was exceeded as t h e hemodialysis concentrate tank had emptied.
A s t a f f member i n attendance,
SAID ET AL.
450 TABLE I PRE-DIALYSIS AND POST-HEMOLYSIS CHEMISTRIES
+
C1
co
mEq/L
mEq3L
Hct
dq/L
135
5.0
90
16.0
20
320
a0
104
4.7
76
9.5
a
250
25
u : 3 0 AM
iia
3. a
75
10.0
12
270
2:30 AM
120
3.0
74
10.8
ia
270
6:OO AM
126
3.1
a0
13.0
ia
278
P redialysis
Downloaded by [RMIT University Library] at 07:20 20 April 2016
k
Na mEq/L
Osm. mosml/L
BUN mg/dl
Posthemolysis
9/23 9:30 PM 9124
observing t h e alarms, f a i l e d t o recognize t h e i r cause.
To o v e r r i d e
t h e alarm he recentered t h e c o n d u c t i v i t y meter p l a c i n g t h e machine i n a s a f e o p e r a t i n g mode, and allowing deionized water t o be pumped through t h e hemodialyzer. a c t i o n s he l e f t t h e d i a l y s i s area.
Without n o t i f y i n g anyone of his Shortly thereafter the patient
became ill. The hemolytic episode which followed occurred as a r e s u l t of osmolar i n j u r y t o RBCs w i t h profound hyponatremia caused by d i a l y z i n g t h e p a t i e n t a g a i n s t deionized water. oemolality dropped suddenly from
The p a t i e n t ' s serum
320 mOsml/L t o 250 mOsml/L with
e x t e n s i v e hemolysis aa evidenced by t h e l e v e l of plasma hemoglobin c o n c e n t r a t i o n and t h e f a l l of hematocrft.
His symptoms w e r e
ACUTE HPi0LYSI.S
451
compatible with t h e p i c t u r e of acute water i n t o x i c a t i o n described by Arieff e t al. (l), and were manifestations of b r a i n edema, r e s u l t i n g i n marked disturbances of consciousness, apprehension, and increased blood pressure.
Downloaded by [RMIT University Library] at 07:20 20 April 2016
The administration of a hypertonic s o l u t i o n of sodium chloride may have been h e l p f u l b u t t h e r e w a s no c l i n i c a l improvement u n t i l t h e p a t i e n t was dialyzed a g a i n s t d i a l y s a t e Na'
130 mEqJL and was transfused.
concentration of
The p a t i e n t ' s symptoms promptly
abated with full c l i n i c a l recovery.
CONCLUSION Suman e r r o r i s most o f t e n t h e cause of d i a l y s i s hemolysis. P a t i e n t s and s t a f f must be constantly r e t r a i n e d to obviate a c c i d e n t a l d i a l y s i s a g a i n s t water. When hemolysis occurs or is suspected i n a p a t i e n t being
dialyzed, t h e treatment should b e stopped and t h e d i a l y s a t e and serum immediately checked f o r sodium concentration.
I f the
d i d y s a t e is hyponatremic, another source of c o r r e c t d i a l y s a t e production must be found i n order t o l i m i t t h e p o s s i b i l i t y of s e r i o u s consequences of acute c e r e b r a l edema.
Promptly dialyzing
t h e hyponatremic p a t i e n t with hemolysis with proper d i a l y s a t e may be l i f e s a v i n g .
SXIIn ET
452
.a.
CHANGE OF ADDRESS
Dr. N . Levin's present address is:
Division of Nephrology Department of Medic;ne Henry Ford Hospital Detroit, M I 48202
Downloaded by [RMIT University Library] at 07:20 20 April 2016
REFERENCE
1.
Allen, I., Arieff, A . , and Guisado, R., Kid. I n t . , g : l W - . i i f i 9 1976.
