Hemolysis in dialized patients caused by chloramines

Normal red cell survival is possible in dialyzed patients. Certain substances like copper and nitrate nitrite induce hemolysis if present in the dialysate. The authors identified another and probably a more frequent cause for hemolysis in dialyzed patients: chloramines. These compounds are becoming more frequent in tap water as large water plants increasingly use chloramines rather than chlorine as bactericidal agents in tap water; they pass reverse osmosis membranes easily; directly induce oxidant damage to red cells with methemoglobin formation; damage the hexosemonophosphate shunt (HMPS) with which red cells defend themselves against oxidant damage; consequently induce hemolysis and short red cell survival time; sensitize the patients to oxidant drugs like primaquine, sulfonamides, etc.; can be removed by charcoal filtration, boiling, or vacuum treatment; and are most expediently neutralized by the addition of ascorbic acid in physiological amounts to the dialysate.