**2. Iatrogenic errors in hemodialysis**

#### **2.1 Iatrogenic hypernatremia in hemodialysis**

Hypernatremia is infrequent in hemodialysis patients and is often iatrogenic when observed. In peritoneal dialysis patients, it is often a result of excessive ultrafiltration. It is critical to be aware of the potential problems associated with dialysate errors, as well as not ignoring the conductivity alarm to ensure that prompt action can be taken to rectify such a situation. Occurrences of hypernatremia errors in dialysate composition have been reported [16–18]. According to Davenport [5], the final dialysate composition is formulated by proportioning the dialysis water with an acid concentrate and a sodium bicarbonate solution. Errors in bicarbonate composition or acid dialysate concentrate can cause hypernatremia [5].

A case report by Kumar et al. [4] showed that a type 2 diabetic patient with hypertension experienced acute hypernatremia leading to altered sensorium during

#### *Iatrogenic Errors in Hemodialysis Practices DOI: http://dx.doi.org/10.5772/intechopen.109493*

hemodialysis. The possible causes for this case were iatrogenic, improper dialysis concentrate, the underlying disease, or overriding of conductivity alarm. Overriding of the conductivity alarm along with improper dialysis concentrate was concluded to be the most appropriate causes. Similarly, Obialo et al. [6] reported two cases whereby ESKD patients with diabetes mellitus who had been on hemodialysis for 7 and 5 years complained of excess thirst and had poorly controlled blood pressure. Upon investigation, it was discovered that the online conductivity meter on their dialysis machine showed normal readings instead of the actual high readings of high dialysate sodium. Hypernatremia and symptoms resolved completely in both patients on replacement of the dialysis machine.

Different dialysis machines apply different techniques to adjust the final concentration of electrolytes and bicarbonate. Although dialysis machines monitor the final dialysate conductivity, not all machines are equipped with a pH monitor. Also, the range of conductivity permitted differs, hence, some dialysis machines are more dependent on both the healthcare provider correctly inputting the right dialysate composition into the dialysis machine and the dialysate manufacturer providing a reliable product. Incorrect input or supply of different composition can lead to patients dialyzing against inappropriately low or high dialysate sodium [16, 17]. Hypernatremic dialysates lead to increased thirst, interdialytic weight gains, and hypertension [5]. Other forms of dialysate composition errors include machine calibration errors, manufacturing errors, temperature reading errors, and errors in the proportioning system. An incorrect conductivity reading on the other hand can cause patients to dialyze on erroneously low or high dialysate sodium [6].
