Nephrology Expert Witness Discusses Buffer Level During Hemodialysis

hemodialysisThis case involves an elderly male with a past medical history of chronic kidney disease (CKD), hemodialysis dependent (HD).  He arrived at the dialysis center one morning and began HD. Vitals and ultrafiltration rate (UFR) were to be monitored throughout receiving HD. Furthermore, the patient received a different formulation of dialysate fluid containing almost double the acetic acid concentration. This led to an increase in buffer level to that of bicarbonate, leading to severe metabolic alkalosis, which caused arrhythmias and cardiovascular collapse. The patient passed away from this complication.

Question(s) For Expert Witness

  • 1. Was the cause of this patient’s condition due to metabolic alkalosis, and could appropriate patient monitoring have improved the outcome?

Expert Witness Response E-004046

Solute is cleared from the intravascular compartment by either diffusive or convective transport. Such transport depends upon multiple factors, including the concentration gradient between the blood and dialysate for a particular solute, the type and amount of blood and dialysate flow, the properties of the dialysis membrane, and the size and physicochemical property of the solute being removed. The purpose of bicarbonate is for it to move passively from the dialysate into the patient’s bloodstream due to them being chronically acidotic. However, this can be dangerous in patients with already elevated bicarbonate levels, hence, alkalotic. Unfortunately, this was the case in this patient. Instead of him being acidotic, he was alkalotic, leading to toxic levels of bicarbonate. Even though the patient was given the wrong dialysate concentration, death could have been avoided had his condition been recognized earlier.


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