Ultrafiltration controller failing: a case report

The development of ultrafiltration controllers has been a major technical progress in haemodialysis. We report the failure of such a controller where the alarm failed to actuate, resulting in a patient weight gain of 3.1 kg over a full dialysis session, instead of a programmed 4.5 kg weight loss; fortunately, the patient recovered completely. Thus the question arises whether such failures may be prevented. In addition, the need for uninterrupted vigilance in haemodialysis monitoring is stressed.