Warning: An Anemia Outbreak Due to Chloramine Exposure in a Clean Hemodialysis Unit—an Issue to Be Revisited

Oliveira, Rubens Marona de; Santos, Carlos Abaeté de los; Antonello, Ivan Carlos Ferreira; Avila, Domingos d ́

doi:10.1080/08860220802546503

Cited by 14 publications

(8 citation statements)

References 13 publications

(19 reference statements)

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“…Thus, total chlorine, which is the sum of free chlorine and bound chlorine (chloramine), is measured from both carbon tanks every 4 hours. The total chlorine level should be ,0.1 parts per million (1 part per million 51 mg/L) (104,112).…”

Section: Emergencies Related To Dialysis Water Systemmentioning

confidence: 99%

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

Saha

Allon

2016

CJASN

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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.

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Section: Emergencies Related To Dialysis Water Systemmentioning

confidence: 99%

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

Saha

Allon

2016

CJASN

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“…Some clinical reports also suggest a role for Br 2 ‐related compounds, such as bromate, a Br 2 ‐based oxoanion, in the development of hemolytic anemia . In addition, chlorine‐related compounds have also been shown to cause anemia . The increases in heme in the bronchoalveolar lavage fluid are possibly derived from the death of inflammatory cells or the sloughing of epithelial cells lining the airways, as evident by the increased number of apoptotic and necrotic cells and elevations in lactate dehydrogenase in the bronchoalveolar lavage fluid of exposed mice .…”

Section: Role Of Heme In Br2‐induced Lung Injurymentioning

confidence: 99%

“…32 In addition, chlorine-related compounds have also been shown to cause anemia. 33 The increases in heme in the bronchoalveolar lavage fluid are possibly derived from the death of inflammatory cells or the sloughing of epithelial cells lining the airways, as evident by the increased number of apoptotic and necrotic cells and elevations in lactate dehydrogenase in the bronchoalveolar lavage fluid of exposed mice. 19 Similar sloughing of airway epithelial cells has been previously shown after chlorine inhalation in rats, 34 pigs, 35 and mice.…”

Section: Role Of Heme In Br 2 -Induced Lung Injurymentioning

confidence: 99%

Role of heme in bromine‐induced lung injury

Lam

Vetal

Matalon

et al. 2016

Annals of the New York Academy of Sciences

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Bromine (Br2) gas inhalation poses an environmental and occupational hazard resulting in high morbidity and mortality. In this review, we underline the acute lung pathology (within 24 hours of exposure) and potential therapeutic interventions that may be utilized to mitigate Br2-induced human toxicity. We will discuss our latest published data, which suggests that an increase in heme-dependent tissue injury underlies the pathogenesis of Br2 toxicity. Our study was based on previous findings that demonstrated that Br2 upregulates the heme-degrading enzyme heme oxygenase-1 (HO-1), which converts toxic heme into billiverdin. Interestingly, following Br2 inhalation, heme levels were indeed elevated in bronchoalveolar lavage fluid, plasma, and whole lung tissue in C57BL/6 mice. High heme levels correlated with increased lung oxidative stress, lung inflammation, respiratory acidosis, lung edema, higher airway resistance, and mortality. However, therapeutic reduction of heme levels, by either scavenging with hemopexin or degradation by HO-1, improved lung function and survival. Therefore, heme attenuation may prove a useful adjuvant therapy to treat patients after Br2 exposure.

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“…There have been many outbreaks of haemolysis in dialysis centres attributed to Chloramine contamination of dialysis fluid …”

Section: Causesmentioning

confidence: 99%

“…There have been many outbreaks of haemolysis in dialysis centres attributed to Chloramine contamination of dialysis fluid. [20][21][22][23][24][25][26] Chloramine is a compound derived from chlorine and ammonium. A large proportion of the chloramine is formed during the water chlorination and disinfection procedure involving the addition of these two agents into the water supply.…”

Section: Chemical Contamination -Chloraminementioning

confidence: 99%

Haemolysis in haemodialysis

Tharmaraj

Kerr

2017

Nephrology

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ABSTRACT:Haemolysis in haemodialysis, although rare in current times, is associated with significant mortality and morbidity. As such prompt recognition, treatment, analysis of root cause and correction of underlying causative factors is crucial. Dialysate, extracorporeal circuit and patient related factors all contribute to haemolysis risk. Haemolysis can manifest with non-specific signs and symptoms including but not restricted to hypertension, nausea, pain (abdominal, chest, back) and dyspnoea. It may present acutely during the dialysis session or may take a protracted course. Potential life threating consequences include; hyperkalaemia induced cardiac arrhythmias, profound anaemia and associated acute coronary events and respiratory distress, and severe necrotizing pancreatitis. Chronic haemolysis results in impaired endothelial function thus contributing to the long-term cardiovascular risk profile in haemodialysis patients. Stringent national and international standards, technological advancements in membrane and dialysis equipment design, dialyser purification methods and water treatment systems have greatly reduced the incidence of haemolysis. Despite these improvements recognition of haemolysis risk and ongoing clinical vigilance is important.

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Warning: An Anemia Outbreak Due to Chloramine Exposure in a Clean Hemodialysis Unit—an Issue to Be Revisited

Cited by 14 publications

References 13 publications

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies

Role of heme in bromine‐induced lung injury

Haemolysis in haemodialysis

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