Detecting Hemolysis During Dialysis

Dear John,

I hope the ADC jet lag has passed. Quick question on how to detect hemolysis during dialysis. I have heard that the spent dialysate will turn pink and the venous blood cherry red if hemolysis occurs during dialysis but I have not been able to find much in the literature. Also the “pink” test with spun blood is about all I can see. Any sources you are aware of would be greatly appreciated.

Thank you,


Detecting hemolysis on dialysis

Thanks, Peter, yes the jet lag has gone but off to Sysdney tonight for the 3 day ANZ Home Therapies (HD and PD) Conference which we hold here biennially.

As for hemolysis on dialysis, there is quite a nice discussion of this relatively rare occurrence at …

This site contains a summary of the 2007 Spring EDTNA/ERCA Journal Club … for those who do not know, EDTNA stands for the European Dialysis and Transplant Nurses Association/European Renal Care Association … where the topic was:

Guarding against hidden hemolysis during dialysis: An overview.

The conclusion of the discussion summary reads as follows (= direct quotation)

[B]Significant hemolysis is a very rare problem in modern day dialysis, however, when it does occur the results are often extremely serious. As well as the classical hemolysis, presenting as strangely coloured or translucent venous blood and often associated with back-pain, there also exists a level of RBC damage that may be visually hidden from clinical staff.

Of the factors that can cause hemolysis, such as inadequate water treatment (eg: chloramine exposure … my words) and faulty dialysis machines or defective consumables, most are likely to affect more than one patient. It is therefore vital that clinical staff are aware of the potential risks and use all the tools and information at their disposal.

From the evidence and practical experience presented in the report, and the ensuing discussion, it may be that a single nurse, recognising one or two patients with slightly unusual back pain towards the end of dialysis, could save the entire next patient shift from far more serious consequences. That the nurse may only see this situation once in their entire career puts into perspective how difficult a task it is we are asking them to perform.

To that end all signs of hemolysis must be acted upon, and organisations should have reporting mechanisms to rapidly decide if any action is required.[/B]

I would suggest you read the discussion as several detection ‘methods’ are discussed in the text.

Thanks John,

I had actually found that link prior. More specifically, does Hb pass the artificial kidney and show up in the dialysate at all? I have seen a couple of conflicting references, but not objective data. I have heard NxStage trainers tell patients to observe for any red tinge in the dialysate as evidence of hemolysis, but once again, I haven’t found anything objective beyond the so called “pink test” with a spun blood sample out of the venous port looking at coloration differences in the plasma. I am thinking it should be too large to pass through the semipermeable membrane, but an objective answer from the literature or from experience would be helpful. I guess that is the essence of my earlier question.

Thank you as always.


With a molecular size in the region of 68,000 dalton (Hb comproses 4 subunits as a tetramer, each subunit being ~17000 dalton), this is way too big a complex to cross an undamaged, unbreached membrane - including the high flux membranes - of standard conventional dialysis.

I suppose that it is conceivable that intact Hb might manage to cross the new high cut-off membranes that we are now using in the treatment of multiple myeloma and which remove light chains of around the 45kDa range but I have not seen objective data reports of this.

Thanks John, that is what I thought, but couldn’t find objective data stating that outright.

Also, I wanted to thank you and Dori for your new book. It truly is a great resource and I am going to show Scott Rasgon the book at my monthly visit this Friday. I believe it is the best new patient source available and wish I would have had one right from the beginning. Where were you five years ago when I needed to know all this? LOL

Thank you indeed.


Re our book ‘Help I need Dialysis’ …

Peter - I think it is a good resource.

There is precious little else ‘out there’.

I am glad you like it.

In my view, it should be in every dialysis unit in the country, on every nephrologists desk and in every waiting room.

The issue is - how can that be achieved? How can nephrologists be made aware of it? How do all units get a copy? Better - dialysis patients should have their own copy.

I know that sounds pecuniary of me - but that is not why it was written. It was written from a genuine belief - shared by Dori and I - that there was no other source available and that is was desperately needed. In my own unit, we have run pre-dialysis classes along the lines of the book structure since the late 70’s/early 80’s. Our default and intent for patients is dialysis in the home. Only our fall-back position is centre-based dialysis. While this is so in Australia, I don’t know if it is the routine in all US services. I suspect it might not be. But … it should be.

What we now need is you - a plural ‘you’ … and others like you - to help to bring the reality of the resource to the attention of ‘Joe-Patient’ out there across the US. Let’s try get people educated. Let’s try to open the renal community to choice and option. All and any help to achieve that will be gratefully received.

I’m interested to know what Scott Rasgon thought of it We sent copies to a couple of other Kaiser So-Cal nephrologists, and I just met one from Kaiser No-Cal. Since I’m in the MidAtlantic region now and have Kaiser healthcare myself, I’m also going to check into the nephrology leadership on this coast and share the book with them. We’ll be exhibiting at all of the major renal meetings, plus the Diabetes Educators and Nurse Case Managers.

Dori, my dialysis brain forgot to bring the book last visit. I will try to take the cobwebs out before going down next time and I am sure he and staff will greatly enjoy your book. It truly is a remarkable collection of renal replacement treatment options. I agree with John, it should be in every dialysis unit, in every patients home and one of the required renal fellow books.

I will let you know what Scott thinks about in about two weeks.