Sudden deaths of Croatian hemodialysis patients in October 2001

In 2001, there were 2,719 patients with chronic renal failure dialyzed in Croatia. Death rate in this patient group was 10.3%, similar to that in other countries. On October 12, 2001, the Croatian Institute of Public Health received information that four patients unexpectedly died in the dialysis center in Pozega General Hospital in a single day. Within a week, a total of 23 dialysis patients died in Croatia, of whom 5 during hemodialysis, and 18 within several hours after hemodialysis. Those events prompted us to assess the epidemiological situation in all hemodialysis centers in Croatia. We used phone contacts and reports of regional centers to collect the data. Clinical picture of the patients before death was characterized by dyspnea, hypotension, and cardiac arrest; resuscitation was unsuccessful in all cases. Analysis of all possible risk elements associated with hemodialysis revealed that dialysis devices, dialyzate, water, and personnel were different in all cases, and that the only common denominator in all events was dialyzer P-15 or P-18, manufactured by Baxter, USA, and distributed by Pliva, Croatia.