Hemolysis is one of the most severe and concerning potential harms related to extracorporeal treatments, particularly chronic hemodialysis (1). Hemolysis is typically deﬁned as the release of hemoglobin into plasma caused by erythrocyte membrane damage (2). Acute hemolysis develops shortly or within hours after exposure to a chemical, thermal, osmotic, or extreme mechanical hazards. In the case of massive erythrocyte damage resulting in a severe decrease in the red blood cell count, noticeable signs and symptoms can be observed within hours (3). Damage is not limited to blood cells, in some cases, plasma proteins may be functionally altered as well. The damage may lead to immediate destruction of the red blood cell (RBC) which is called acute hemolysis or to functional impairment resulting in its short-term elimination by the human body (1).
Fortunately, as a result of technological progress, hemolytic events during hemodialysis are now very rare. Hemodialysis has become a routine outpatient and/or home-based treatment. If technical issues do occur, these are the most common causes related to operating procedures (3–5):
- High blood pump flow
- Single-needle dialysis
- Small gauge cannula
- Kinked blood lines
- High negative arterial pressure
- Offset blood pump
- Failure of rinsing
- Hydrogen peroxide
- Contamination with
- Priming error
- Hypotonic saline
- Dialysate error
- Hyper or hypotonic dialysate
- Overheated dialysate
- Dialysate contamination
Signs & Symptoms
The most common symptoms are non-specific and may include nausea, vomiting, and abdominal pain (6). Other symptoms may be shortness of breath, chest pain, back pain and headaches (4). On physical examination and procedure assessments, some patients have been found to have worsening hypertension (6), as well as skin pigmentation, port-wine appearance of blood in the venous bloodline, and pink discoloration of the plasma in centrifuged samples (4). If hemolysis is not identified opportunely, potassium content in the erythrocytes would be massively released into the bloodstream causing severe hyperkalemia that may lead to muscle weakness, electrocardiographic disorders and ultimately cardiac arrest (4). As another possible sign of hemolysis during hemodialysis, arterial oxygen tension may drastically decrease by up to 25%, this occurrence does not usually cause symptoms, unless the patient has a severe cardiac and/or pulmonary dysfunction (5).
- The diagnosis of hemodialysis-induced hemolysis demands a high level of vigilance. In all cases, patients should be transferred to the emergency department after stopping hemodialysis session (6). Patients need to be closely monitored and hospitalization should be considered due to delayed hemolysis (4). Immediate management typically includes monitoring of blood count, reticulocyte count, levels of haptoglobin, free hemoglobin, lactate deshydrogenase and methemoglobin (4). Due to its serious nature and potential life-threatening complications, it is imperative to keep hemolysis as a part of the differential diagnosis, especially in the presence of acutely worsening anemia (6).
- If hemolysis is suspected during HD, the patient’s blood in the extracorporeal dialysis circuit should not be reinfused and should be discarded. This is an important step to lower the risk of hemolysis related complications such as hyperkalemia and related arrhythmias (6). Regardless preventive actions, severe hyperkalemia may occur, therefore additional dialysis may be required (4,5) as well as other measures such as the oral or rectal administration of a Na/K ion exchange resin (4). In some cases, depending the degree of severity oxygen supply and blood transfusion should be also considered (5).
Although, risk of acute hemolysis can be minimized by industrial quality control, better design of dialysis equipment, and hemodialysis machine assessment, these are some measures that can prevent the incidence of hemodialysis-induced hemolytic episodes (4,5):
- Test machine prior to use to ensure that the air detector alarm system is working effectively
- Avoid chemical contaminants that can damage RBC’s
- Oxidants such as chloramines, copper, zinc
- Reducing agents such as formaldehyde, hypo or hypertonic dialysate
- Overheated dialysate
- Avoid small needles
- Highly negative arterial pressure alarms
- Ensure correct positioning of tubing in the roller pumps
- Avoid accidental compression of lines
- Polaschegg H-D. Red blood cell damage from extracorporeal circulation in hemodialysis. Semin Dial. 22(5):524-531.
- Taskin ME, Fraser KH, Zhang T, Gellman B, Fleischli A, Dasse KA, Griffith BP, Wu ZJ. Computational characterization of flow and hemolytic performance of the UltraMag blood pump for circulatory support. Artif Organs. 2010;34(12):1099-1113. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20626739.
- Duffy R, Tomashek K, Spangenberg M, Spry L, Dwyer D, Safranek TJ, Ying C, Portesi D, Divan H, Kobrenski J, et al. Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets. Kidney Int. 2000;57(4):1668-1674.
- Blake PG, Daugirdas JT, Ing TS. Handbook of Dialysis. 4th ed. (Blake PG, Daugirdas JT, Ing TS, eds.). Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
- Davenport A. Intradialytic complications during hemodialysis. Hemodial Int. 2006;10(2):162-167.
- Yoon J, Thapa S, Chow RD, Jaar BG. Hemolysis as a rare but potentially life-threatening complication of hemodialysis: a case report. BMC Res Notes. 2014;7:475.
P/N 103063-01 Rev A 03/2021