Assessing Anemia Secondary to Hemolysis in Hemodialysis Patients

Nephrology Nursing Journal, April, 2001 by Jamie Behrens

Medications: Pharmaceuticals can cause hemolysis through several mechanisms. Some medications mount an oxidative attack in which they insert themselves into the oxygen-binding cleft of Hb, causing RBC destruction. Others cause immune-mediated hemolytic anemia by either precipitating the development of autoantibodies that attack RBCs (autoimmune mechanism), or combining with the red cell membrane to induce antibody directed against the cell-bound drug (immune complex mechanism). (Schrier, 1999). In patients who show evidence of hemolysis, drugs should be reviewed and the prescription modified if medication is determined to be the cause. A partial listing of the mechanisms of drug-induced hemolysis and representative medications is provided in Table 1.

Table 1: Medications That May Cause Hemolysis

Treatments that can cause immune complex hemolysis

* Stibophen            * Chlorpromazine        * Aminosalicylic acid
* Isoniazid            * Rifampin              * Quinidine, quinine
* Chlorpropamide       * Immunosuppressants    * Penicillins
* Cephalosporins       * Sulforamieds and
                         sulfonylureas

Treatments that can cause autoimmune hemolytic anemia

* Methyldopa           * Levodpa               * Mefenamic acid
* Procainamide         * Diclofenac sodium

Treatments that can cause oxidative hemolysis

* Dapsone              * Sulfasalazine         * Phenacetin
* Sodium perchlorate   * Nitroglycerin         * Phenazopyridine
* Primaquine           * Vitamin K analogues

Hypotonic and hypertonic dialysis: Hypotonic and hypertonic dialysis are extreme emergencies that can result in abrupt hemolysis, acute water intoxication, and cerebral edema. Manifestations can include burning pain in the venous return site, dyspnea, chest pain, restlessness and headache, acute lumbar pain, confusion, increased pulse rate, cold and clammy skin, seizures, coma, and cardiac arrhythmia or arrest. Blood lines should be clamped immediately, and hemolyzed blood should not be returned to the patient. Hospitalization may be needed to rule out myocardial injury and monitor for hyperkalemia (Ismail & Hakim, 1992).

Faulty dialysis equipment or procedures: Although modern blood pumps have low shearing stresses that should not cause hemolysis, blood pump rollers may cause cellular damage if they are not calibrated correctly. Hemolysis can also be caused by mechanical trauma if blood is forced through a crimped or obstructed segment of dialysis tubing. Moreover, low blood flows, especially when they are accompanied by high blood pump speed, can exert enough negative pressure on RBCs to cause hemolysis. (Denker, Chertow, & Owen, 2000). Overheated ([is greater than] 47 [degrees] C) or underheated ([is less than] 35 [degrees] C) dialysate can lead to hemolysis that can last for days or weeks. Similarly, formaldehyde and other disinfectants--including acetic acid, peracetic acid, and hydrogen peroxide--can be noxious to RBCs and cause hemolysis (Jaber & Pereira, 1999; Kjellstrand, 1993).