TABLE 4.
Outbreaks and adverse events caused by chemical intoxication associated with water in the dialysis setting within the United States (modified from Arduino et al. (15)). The 13 events listed below occurred between 1960 and 2007 for a total of 217 cases and 14 deaths
| Contamination | Description; cause | References |
|---|---|---|
| Aluminum | Intoxication and seizures in 7 patients; exhausted deionization tanks unable to remove aluminum in incoming tap water |
(73) |
| Intoxication neurologic symptoms, dementia and elevated serum levels in 64 patients, 3 deaths; aluminum pump was used to transfer acid concentrate to the treatment area |
(76) | |
| Elevated serum levels detected in 10 patients during routine screening; replacement pump used to pump acid concentrate contained aluminum components |
(77) | |
| Chloramine | Hemolytic anemia in 41 patients; residual disinfectant was not removed completely by the carbon tank when the facility increased the capacity of the water treatment system |
(74) |
| Copper | Hemolytic syndrome in 12 patients, 32 episodes with 4 fatalities; six hemodialysis centers had partially exhausted deionization system resulting in low pH water causing the formation of copper ions |
(28) |
| Fluoride | Intoxication in 8 patients, 1 death; accidental spill in hydrofluosilic acid at drinking water plant lead to excessive fluoride levels entering dialysis unit, insufficient treatment prior to dialysis |
(25) |
| Intoxication in 9 patients, 3 deaths; exhausted deionization tanks discharged a bolus of fluoride |
(24) | |
| Formaldehyde | Intoxication in 5 patients, 1 death; disinfectant not properly rinsed from the distribution system |
(105) |
| Intoxication in 12 patients; new filtration system was installed and not properly rinsed |
(80) | |
| Hydrogen peroxide | Decreased hemoglobin in 3 pediatric dialysis patients; H2O2 used to disinfect the system was not adequately rinsed from the system due to a flat bottom storage tank that could not be rinsed |
(78) |
| Nitrate | Patient developed methemoglobinemia; home dialysis using well water that contained nitrate nitrogen (94 mg/l) |
(27) |
| Sodium azide | Severe hypotension in 9 patients; dialysate contaminated with sodium azide used as a preservative from new ultrafilters, which were labeled “not for medical use” |
(79) |
| Sulfate(s) | Nausea, vomiting, chills, some with fever in 16 patients, 2 deaths; source water used to prepare dialysate contained volatile organic compounds (CS2, CH3, etc.) and additional failures |
(75) |