Lack of Due Diligence Can be Deadly for Dialysis Patients

Lack of Due Diligence Can be Deadly for Dialysis Patients

The Centers for Disease Control and Prevention estimates more than 20 million people in the United States suffer from chronic kidney disease.

Diabetics or individuals with elevated blood pressure are considered to be at higher risk than others of suffering the condition. In fact, the American Diabetes Association says diabetes is the main cause of end-stage kidney disease and those in that condition typically receive dialysis treatments.

Such patients face the ordeal of having to go to the hospital, several times a week in some instances, where they are hooked up to a dialysis machine to have their blood cleansed. It’s a life-extending treatment, but it requires close monitoring. If staff falls down on the job and monitoring errors occur, the results can be fatal.

The Institute for Safe Medication Practices is a nonprofit organization dedicated to educating consumers and medical professionals about such dangers. Not long ago, it issued a warning about some portable glucose monitoring devices used by some hospitals and the fact that they can deliver false readings.

Of specific concern is a product called Extraneal — a dialysis solution made with icodextrin. According to the ISMP, the body metabolizes icodextrine into a form of sugar called maltose. The Food and Drug Administration has recorded at least 18 instances since 2002 in which patients on icodextrine suffered hypoglycemic adverse events. In one 2008 case, a man died.

Officials say the problem is that certain portable glucose monitoring devices don’t distinguish between glucose and other sugars that might be in the patient’s blood. As a result, they may give a false reading that prompts insulin treatment that could kill.

What is most disturbing in the report is that, in some cases, patients or their families had told hospital staff to be alert to the possibility of such readings, but the information was apparently ignored. In the fatal 2008 case, hospital lab tests showed the patient had much lower glucose readings than the portable device revealed, but the lab results weren’t relied upon.

Missouri readers may take solace knowing that warnings have been issued and recommendations made to reduce the chance of such errors, but it is clear that mistakes still occur. When they do, hospitals should expect to be held accountable.

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