1. Haemodialysis Associated Haemolysis
Lessons from the Northern Ireland Cluster
Dr Henry Brown

2. Background Causes of Haemolysis Dialysate problems eg hypotonicity
Water contamination
Faulty roller clamps
Kinking of Lines
Construction faults with lines

3. Index Case 44 year old female
ESRD 2 o PCKD on haemodialysis for 42 months
During routine HD session developed nausea,
vomiting, abdominal pain, hypertension
Haemolysis – red supernatant, raised LDH,
fall in Hb of 3g/dl
Inability of lab to report K+ and other common variables
Raised amylase, subsequent radiological evidence
of acute pancreatitis
Symptoms settled quickly

4. More than one Dialysis Unit
Other Cases
More than one Dialysis Unit
A Problem to be Addressed

5. Actions taken
Internal Review
Meeting with Industry & NIAIC
Investigation
Measures to protect patient safety
Search for other cases
MHRA visit

6. August 2008 –May 2009
Trigger case

7. Distribution of Cases 3 4 6 3

8. Possible explanation NO NO NO Contaminated water/dialysate
Damaged/faulty lines NO NO
Patient related factors

9. Kink
Arterial
Port
Kidney
Venous
Port

10. Learning points Potential cause of significant morbidity / mortality
May go unrecognised
Aetiology may be difficult to identify
Importance of staff vigilance
Importance and benefit of clinical networks