When pure is not so pure: Chloramine‐related hemolytic anemia in home hemodialysis patients

Worldwide, chloramines are used as the preferred disinfectant for city water supplies. Although they have distinct advantages compared with chlorine and are deemed harmless to the general population, hemodialysis (HD) patients are at risk from chloramine‐induced hemolytic anemia. In recent years, this has been highlighted in regional dialysis units but not as frequently in the home HD group. We report on 2 home HD patients who succumbed to severe oxidative hemolysis due to high mains water chloramine concentrations. Both patients were extensively investigated for other cause of anemia before a definitive diagnosis was reached. Delays in diagnosing this uncommon condition can be costly in terms of significant morbidity and excessive usage of recombinant erythropoietin and blood transfusion. Prevention primarily involves enforcing strict water quality control and establishing regular communication with water supply boards and home HD patients. Double (inline) carbon filters should be installed in patient's homes as an effective means for removing high incoming chloramine concentrations.

[1]  B. Jaber,et al.  Hemodialysis-associated methemoglobinemia in acute renal failure. , 2002, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[2]  A. Kitching,et al.  Chloramine-induced hemolysis associated with neurological symptoms in a home hemodialysis patient. , 2001, Clinical Nephrology.

[3]  C. Bartlett,et al.  Erythropoietin resistance due to dialysate chloramine: the two-way traffic of solutes in haemodialysis. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[4]  R. Pérez-García,et al.  Chloramine, a sneaky contaminant of dialysate. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[5]  J. Cross.  The development of water treatment technology for hemodialysis , 1997 .

[6]  D. Ward.  Chloramine removal from water used in hemodialysis. , 1996, Advances in renal replacement therapy.

[7]  Soo‐Hun Cho,et al.  An Outbreak of Heinz Body Positive Hemolytic Anemia in Chronic Hemodialysis Patients1 , 1993, The Korean journal of internal medicine.

[8]  G. White.  The Handbook of Chlorination and Alternative Disinfectants , 1992 .

[9]  M. Arduino,et al.  Illness in hemodialysis patients after exposure to chloramine contaminated dialysate. , 1991, ASAIO transactions.

[10]  J. Villforth.  FDA safety alert: chloramine contamination of hemodialysis water supplies. , 1988, American Journal of Kidney Diseases.

[11]  M. Grisham,et al.  Preparation and characterization of chloramines. , 1986, Methods in enzymology.

[12]  M. Grisham,et al.  Cytotoxicity of chloramines. , 1986, Methods in enzymology.

[13]  A. Lewins,et al.  WATER SUPPLY ALUMINIUM CONCENTRATION, DIALYSIS DEMENTIA, AND EFFECT OF REVERSE-OSMOSIS WATER TREATMENT , 1982, The Lancet.

[14]  M. Torres,et al.  Chloramines, an aggravating factor in the anemia of patients on regular dialysis treatment. , 1977, Proceedings of the European Dialysis and Transplant Association. European Dialysis and Transplant Association.

[15]  J. Eaton,et al.  Hemolysis in dialized patients caused by chloramines. , 1974, Nephron.

[16]  J. Eaton,et al.  Chlorinated Urban Water: A Cause of Dialysis-Induced Hemolytic Anemia , 1973, Science.

[17]  C. Kjellstrand,et al.  HEMOLYSIS IN DIALYZED PATIENTS: TAP WATER‐INDUCED RED BLOOD CELL METABOLIC DEFICIENCY , 1972, Transactions - American Society for Artificial Internal Organs.

[18]  M. Chamberlain,et al.  Hard-water syndrome. , 1967, The New England journal of medicine.

[19]  H. T. John,et al.  HYDROCORTISONE IN SEVERE MYOCARDIAL INFARCTION. TRIAL CONDUCTED BY THE SCIENTIFIC SUBCOMMITTEE OF THE SCOTTISH SOCIETY OF PHYSICIANS. , 1964, Lancet.