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

Abstract

BackgroundThe 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 presentation66-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.ConclusionIt 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.

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

“…Red blood cells (RBCs) undergo shear stress when they circulate through the HD circuit, and are, therefore, at risk for fragmentation. Additionally, blood osmotic changes, dialysate contaminants, or hyperthermia may each enhance hemolysis (Table 3) (49)(50)(51)(52). Because blood flow is higher at the center of a laminar flow than at the edges (wall) of the extracorporeal circuit, the RBC membrane is exposed to a differential force on two different sides, thereby causing a shear stress (51).…”

Hemolysis in Hemodialysis, Secondary to Severe Vena Cava Stenosis

“…The causes of hemolysis described so far can be divided into: chemical agents, such as contamination of the dialysis fluid by chlorine, copper, zinc, chloramines, and formaldehyde; patient-specific causes, such as malignant hypertension, autoimmunity, sickle cell anemia, glucose-6-phosphate dehydrogenase deficiency; or infectious ones like malaria; some medications, such as aspirin, penicillins, cephalosporins, sulfonamides, sulfones, nitrofurantoin, primaquine, quinidine, hydralazine, certain derivatives of vitamin K [ 2 ]; and finally, mechanical causes, such as fibers on the surface of old dialysis membranes, overheating of the dialysate fluid, error in the manufacture of the circuit, kinking or bad position of the lines, stress due to low-caliber needles, increase in negative pre-pump pressure [ 6 ], small diameter of the hoses [ 5 , 7 ], and there are some anecdotal reports of the use of subclavian catheters associated with partial occlusion of the catheter due to thrombi or clots at the tip of the catheter [ 8 ].…”

“…dialysis could be carried out without problems, and there were no new episodes of hemolysis; therefore, the cause was resolved. An active search of the etiology for an early and appropriate intervention reduces the risk of morbidity and mortality, which is already high in patients with kidney disease on dialysis [ 5 , 7 , 11 ].…”

Haemolysis in haemodialysis

“…Acute, severe haemolysis commonly presents with dyspnoea, gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhoea) back pain, chills and hypertension . Other noted symptoms include cyanosis, headache, chest pain, palpitations, lethargy, malaise, diaphoresis, hypotension, dark urine and death.…”

“…Acute, severe haemolysis commonly presents with dyspnoea, gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhoea) back pain, chills and hypertension. 1,8,[71][72][73] Other noted symptoms include cyanosis, headache, chest pain, palpitations, lethargy, malaise, diaphoresis, hypotension, dark urine and death. Duffy 8 found that during the 1998 outbreak of haemolysis due to kinked blood tubing, the majority of patients developed hypertension (66%) and abdominal pain (60%).…”