Accidental metabolic acidosis during hemodialysis

Three incidents of metabolic acidosis during hemodialysis in 3 different patients are presented. Two patients became severely ill but recovered completely after treatment. In the third patient, the event was recognized before the acidosis became symptomatic. In all cases the acidosis was caused by an unbalanced supply of acidic dialysis concentrate. Two events were caused by mistaking acidic dialysis concentrate for acetate. In the third patient, the supply line from the bicarbonate concentrate jug was broken. The conductivity cell alarm was not activated during any of the incidents and in only 1 case during reconstruction of the accidents. The efficacy and safety of the conductivity cell alarm system regarding prevention of acid/base disturbances during hemodialysis are discussed.