Abstract
Blood leakage alarm is a critical incident, which means blood has directly contacted dialysis fluid without the barrier of the dialyzer membrane. Recently, even though the technology of sterilization of dialysate has been widely distributed and the level of sterilization of the dialysate has been guaranteed in many dialysis centers, the critical incident of blood leakage in dialysis centers where the sterility of dialysate is insufficiently high still occurs, which may cause endotoxin and/or bacterial contamination of blood. Here, we report a case in which, although blood leakage could be observed on the output side of the dialyzer during sounding of the blood leakage alarm, the alarm could not be canceled by changing the dialyzer, so the cause of this alarm might have been pseudo-blood leakage. A 77-year-old female had been undergoing hemodialysis (HD) due to renal dysfunction accompanied by heart failure. The mode of dialysis was 3 hours of HD and 1 hour of ECUM, for a total of 4 hours. On the day of treatment, after changing the dialysis mode from HD to ECUM, the blood leakage alarm sounded. After changing the dialyzer to another of the same type, the dialysis was resumed, but the blood leakage alarm again sounded and could not be canceled. There was no damage observed on the dialyzer membrane, and there was also no problem in terms of the condition of the sensor of blood leakage. As the blood haptoglobin was lower than 10 mg/dL, there should have been hemolysis. Therefore, this hemolysis could not have been due to hemodialysis, but would rather have been pseudo-blood leakage due to mechanical hemolysis by prosthetic heart valves. When the blood leakage alarm sounds in hemodialysis patients undergoing heart valve replacement, we may consider the possibility that this alarm has been caused by pseudo-blood leakage due to mechanical hemolysis by prosthetic heart valves.
