Nephrology Dialysis Transplantation, Vol 14, Issue 7 1687-1691, Copyright © 1999 by Oxford University Press
S Fluck, W McKane, T Cairns, V Fairchild, A Lawrence, J Lee, D Murray, M Polpitiye, A Palmer and D Taube
Background: In December 1996 we identified an outbreak
of erythropoietin (rHuEpo) resistance requiring a substantial increase in
rHuEpo dosage in one of our four haemodialysis (HD) units. The dialysate
chloramine levels in this unit had risen from <0.1 p.p.m. in 1996 to
0.25-0.3 p.p.m. in 1997. In the other three HD units levels remained
<0.1 p.p.m. Other parameters of water quality were within accepted
standards. Methods: Monthly records of haemoglobin
level and rHuEpo dose were available for 148 patients between January 1996
and May 1998. Seventy-two patients, with no recognized cause of rHuEpo
resistance, were analysed in detail (August 1997 to April 1998). A subgroup
of 15 patients was examined for evidence of haemolysis during HD
(methaemoglobin and haptoglobin levels, reticulocyte counts and Heinz
bodies). Larger carbon columns were installed in December 1997 to effect
chloramine removal. Results: There was an increase in
mean methaemoglobinaemia of 23% (P<0.01) and a 21% fall in mean
haptoglobin (P<0.01) across HD, although no patient had a
reticulocytosis and only one patient with G6PD deficiency had Heinz bodies.
Following installation of larger carbon columns there was an 18.6% rise
(P<0.001) in mean haemoglobin level and a subsequent 25.0% reduction
(P<0.001) in mean rHuEpo dose. Intradialytic changes in
methaemoglobin and haptoglobin were abolished. The dialysate chloramine
levels fell to <0.1 p.p.m. Water company records subsequently
revealed a sustained twofold increase in mains water chloramine from
November 1996. Conclusions: This is the first report
linking chloramine exposure and rHuEpo resistance, with only subtle signs
of haemolysis. Unheralded changes in mains water constituents can directly
affect dialysate water quality and clinical outcomes. Key
words: chloramine; erythropoietin; haemodialysis; haemolysis;
water quality
ORIGINAL ARTICLES
Chloramine-induced haemolysis presenting as erythropoietin resistance
The Brent Laboratory and Renal Unit, St Mary's Hospital, Praed Street, London W2 1NY, UK; Renal Unit, Lister Hospital, Stevenage, UK; Corresponding author
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