Hemolysis Associated with Hydrogen Peroxide at a Pediatric Dialysis Center

Vol. 10, No. 2, 1990

Free Abstract Article (PDF 2116 KB)

Clinical Study

Hemolysis Associated with Hydrogen Peroxide at a Pediatric Dialysis Center
Steven M. Gordon^a, Lee A. Bland^a, Steven R. Alexander^b, Frank Newman^c, Matthew J. Arduino^c, William R. Jarvis^a

^aHospital Infections Program, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Ga.;
^bDepartment of Pediatrics, University of Texas, Southwestern Medical Center, and Children's Medical Center of Dallas, and
^cSouthwest Region, Food and Drug Administration, Dallas, Tex., USA

Address of Corresponding Author

Am J Nephrol 1990;10:123-127 (DOI: 10.1159/000168066)

Key Words

Hydrogen peroxide
Hemolysis
Hemodialysis

Abstract

Patients receiving hemodialysis therapy risk exposure to disinfectants used to reduce bacterial burdens in hemodialysis equipment and to reprocess hemodialyzers. From April 29 through May 9, 1988,3 patients undergoing hemodialysis treatments at a single center were exposed to dialysis fluid that was inadvertently contaminated with hydrogen peroxide (HP). All patients showed a significant decline in blood hemoglobin level and required packed red blood cell transfusions during the 11-day exposure to HP. Contamination of dialysis fluid may have been due to the inadequate rinsing of HP from the water treatment system (WTS) following its disinfection on April 27-28, 1988. The failure to check water at point-of-use stations with a sensitive enough test kit after the disinfection for HP permitted patient exposure to contaminated dialysis fluid. To prevent similar occurrences, we recommend that after each disinfection (or other modifications of the WTS), the WTS be adequately rinsed to remove potentially toxic chemicals. Dialysis center personnel need to be aware of the potential effects that each modification or disinfection of the WTS may have on the product water used.

Author Contacts

Steven M. Gordon, MD, Hospital Infections Program, Center for Infectious Diseases, Centers for Disease Control Atlanta, GA 30033 (USA)

Article Information

Received: April 26, 1989
Accepted: October 23, 1989
Published online: October 28, 2008
Number of Print Pages : 5

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