Naslov
Unexpected hemodialysis - related deaths in Croatia

Autori
Gašparović, Vladimir ; Ostojić, Ranko

Izvornik
Journal of Nephrology (1121-8428) 15 (2002), 2; 194-197

Vrsta, podvrsta i kategorija rada
Radovi u časopisima, članak, znanstveni

Ključne riječi
chronic hemodialysis; sudden deaths; perfluorocarbon

Sažetak
Until recently mortality rates of chronic hemodialysis patients in Croatia was 10, 26% and did not greatly differ from those in other countries. The tragic events that occurred in October 2001 resulted in 23 unexpected deaths of patients on chronic hemodialysis in a single week. Five patients died during hemodialysis and an additional 18 patients died within several hours after hemodialysis had been completed. The clinical presentation was characterized by dyspnea and hypotension, followed by cardiac arrest. Standard resuscitation measures were unsuccessful. These deaths pointed to an acute incident which had to be promptly identified in order to prevent further loss of life. To illustrate how dramatic these incidents were, let us just say that five patients died in a small regional center in a single day. Once the initial epidemiologic data was obtained, simulation of hemodialysis on a model was performed. In all 23 patients who died during or shortly after hemodialysis P15 or P18 dialyzers were used. The mentioned dialyzers (P15 and P18) were manufactured by Baxter and distributed by Pliva. Effluent samples were gathered to be study by gas chromatography. Dialysate, AV lines, water and staff were different and no correlation was found between these factors and the deaths. Fourteen patients underwent an autopsy. The autopsy findings consistant with end stage renal disease were found as were unusual foaming of blood and dilatation of heart chambers. According to the data provided by the manufacturer, perfluorocarbon which is used in the fiber stabilization process in the mentioned dialyzers may be responsible for the noted clinical picture since similar observations were made in an experimental model.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

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