Can hemolysis be visually identified in blood lines during hemodialysis in patients with End-Stage Renal Disease (ESRD)?

Visual Identification of Hemolysis in Hemodialysis Blood Lines

Yes, hemolysis can be visually identified in blood lines during hemodialysis, and this visual recognition is a critical early warning sign that should prompt immediate investigation and intervention to prevent serious patient harm.

Clinical Recognition of Hemolysis

Visual inspection of the extracorporeal circuit during hemodialysis can reveal hemolysis through characteristic changes in blood appearance:

• Pink or red discoloration of the plasma in the blood lines indicates free hemoglobin from lysed red blood cells, which becomes visible when hemolysis is occurring 1, 2
• Darkening or abnormal coloration of blood in the circuit may be observed when mechanical injury to erythrocytes is occurring 1, 2
• In documented outbreak investigations, hemolysis was visually evident in experimental closed-loop blood systems within 30 minutes when blood lines were kinked, producing plasma hemoglobin concentrations of 40 g/L 1

Mechanical Causes Detectable by Visual Inspection

The most common causes of acute intravascular hemolysis during hemodialysis are mechanical and can be identified through careful visual examination:

• Kinked blood lines at the dialyzer inlet port or just below the arterial line tubing organizer are a primary cause of hemolysis 1
• Partially occluded blood tubing creates increased pressure on erythrocytes as they pass through narrowed apertures, causing mechanical destruction 2
• Improperly fitted blood lines with extra-long pump segments that fit poorly in tubing organizers can cause severe kinking without triggering pressure alarms 1

Clinical Presentation Requiring Immediate Action

When hemolysis occurs during hemodialysis, patients develop acute symptoms that should prompt immediate visual inspection of the blood lines:

• Malaise, nausea, and headache are universal early symptoms 1
• Severe abdominal pain occurs in approximately 60% of cases 1, 2
• Hypertension develops in approximately 66% of affected patients 2
• Laboratory confirmation shows plasma hemoglobin levels of 3-21 g/L and markedly elevated LDH (542-3,300 IU) 1

Critical Action Steps

When hemolysis is suspected based on visual inspection or clinical symptoms, immediately:

1. Stop the dialysis treatment and inspect all blood lines for kinks, occlusions, or mechanical defects 1, 2
2. Do not return blood from the extracorporeal circuit to the patient if significant hemolysis is visible 1
3. Document the lot numbers of all disposable blood tubing sets, as manufacturing defects have caused multistate outbreaks affecting 30 patients across three facilities 2
4. Measure plasma hemoglobin and LDH to confirm and quantify hemolysis 1

Common Pitfalls to Avoid

• Do not assume pressure alarms will detect all mechanical problems—severe kinking can occur without triggering alarms if positioned just after the pump segment 1
• Do not overlook blood line configuration issues—improperly fitted tubing with extra-long pump segments creates high-risk situations 1
• Do not dismiss early symptoms—malaise and nausea may precede severe complications including intensive care unit admission (36% of cases) and death 2
• Do not use blood tubing sets from implicated lots—manufacturing defects causing narrowed apertures have resulted in voluntary nationwide recalls 2

Prevention Through Visual Monitoring

Regular visual inspection of the extracorporeal circuit during hemodialysis sessions is essential:

• Check blood line positioning at the start of each treatment to ensure proper fit in tubing organizers without kinking 1
• Monitor blood appearance throughout the dialysis session for any color changes suggesting hemolysis 1, 2
• Verify blood line compatibility with the specific dialysis delivery system being used 1