Fatal events on chronic hemodialysis (HD) in Croatia

Introduction

In the year 2000, 2719 chronic renal failure patients in Croatia underwent chronic HD, the reported mortality was 10.3% which was not different from other countries. From 8 to 13 October 2001, 23 sudden and unexpected deaths during HD or within several hours thereafter were recorded.

Patients and methods

All dead 23 patients were dialyzed on cellulose diacetate membrane P15 (15 patients) and P18 (8 patients) in six dialysis centers. One patient suffered from metastatic uterine cancer with ascites, but was still ambulatory and in satisfactory condition. She died at home, within 2 hours of the termination of her HD. Another patient had a history of a coronary incident 8 days prior to death which occurred 37 hours after dialysis. In these two patients we must appreciate comorbidities but the clinical picture still pointed to a sudden death related to the HD. In all other 21 patients, the death was unexpected and associated with the above mentioned dialyzers. All other materials were different. All P15 dialyzers had the control number 2001F07 P, and all P18 dialyzers had the control number 2001B17R.

Discussion

Sudden death on HD is infrequent, and mostly cardiovascular events are reported as causes. Death occurred within 2 hours of the onset of HD or in the first hours after completion of dialysis. The clinical presentation was dominated by sudden worsening of the general condition accompanied by suffocation, chest pain, sweating, and in some cases generalized convulsions. Despite resuscitation in the hospital all 16 patients died. The other seven pts died at their homes. Autopsy findings pointed to foaming of blood. Effluent samples from incriminated dialyzers showed different gas chromatography findings (perfluorocarbon?) compared to other control cellulose diacetate dialyzers.

Conclusion

Sudden deaths during HD or in the first hours after dialysis are in causal relationship with dialyzers of cellulose diacetate manufactured by Baxter, distributed by Pliva, under designations P15 and P18. After withdrawal of the incriminated dialyzers no new lethal events were recorded.