Federal and state health authorities are investigating a rare outbreak of illness among dialysis patients in Maryland and at least two other states that has left one Marylander dead and more than 30 people ill.
The culprit, physicians believe, may be a step in the dialysis process, which cleans the blood of people whose kidneys do not function properly. Investigators said yesterday they are considering many possibilities, including problems with the equipment, water, or other fluids used in the dialysis process.
Bon Secours Baltimore Health Systems operates the three centers where the sick patients were receiving dialysis. Bon Secours voluntarily closed those centers late Saturday, shifting patients temporarily to others.
The three closed dialysis centers are at Bon Secours Hospital at 2000 W. Baltimore St. in West Baltimore, Bon Secours Center at 120 N. Langley Road in Glen Burnie, and Charing Cross Center at 5208 Baltimore National Pike in Baltimore County. Bon Secours is one of Maryland's largest dialysis providers, regularly serving more than 300 patients.
In other places where Bon Secours performs dialysis, officials said they have changed the equipment they are using and are monitoring patients every 15 minutes.
Bon Secours officials initially identified nine cases, including one death. Last night, they reported that in searching through records from Thursday to Saturday, four more cases were identified, including a second death that may be related to the illness.
'This is an outbreak'
A team from the U.S. Centers for Disease Control and Prevention was in Lincoln, Neb., yesterday, studying 14 cases similar to those in Maryland, trying to find out what went wrong. The team is coordinating its work with Maryland officials and with that of health investigators in Massachusetts, where about five cases were reported. Because the machines and supplies used in dialysis are regulated by the U.S. Food and Drug Administration, that agency also is examining the cases.
"This is an outbreak," said Dr. Bill Jarvis, acting director of the hospital infections program at the Atlanta-based CDC. He asked any dialysis patient with symptoms or episodes similar to those reported to notify the Maryland health department and the CDC.
The cases in Maryland surfaced late last week, when two patients with sunburn-type rashes showed up about the same time in the emergency room at Bon Secours Hospital. The patients also suffered from nausea and cramps. Both were dialysis patients at Bon Secours. Physicians realized these unusual cases were probably linked.
"This is limited, and there is no evidence that it is communicable," said Dr. Diane Dwyer, director of epidemiology and disease control for the state Department of Health and Mental Hygiene. "It's a cluster of cases that in the individual can be severe, but without dialysis, people would die very quickly."
Dwyer said she and her staff were reviewing charts, checking lot numbers, suppliers and dates, trying to find a common factor.
This is what is known so far: The patients had similar symptoms, during or after their dialysis. Most patients were monitored in hospitals, and most recovered, although they all have underlying illnesses such as diabetes and hypertension, which complicate the picture.
Several of the patients remain hospitalized, said Dr. William R. Law, chief medical officer of Bon Secours Baltimore Health Systems. He said they need to stay there to be treated for their other health problems.
The patients did share one trait: Their red blood cells were bursting, letting out essential oxygen and energy. This condition, known as hemolysis, can be caused by some internal body process, or, as investigators believe is the case here, something occurring outside the body.
Possible trouble spots
In dialysis, there are several points where something could go wrong.
The patient's blood flows to the machine through a tube, and once inside, is put through a membrane, which filters small waste particles. The clean blood then flows through tubing back the patient.
Equipment that was disinfected with a chemical and not properly rinsed out could cause hemolysis. One particular manufacturer's tubing, which is replaced for each patient, could have a powder or chemical contaminant in it. Another possibility is the municipal water, which dialysis centers routinely purify. Jarvis said that sometimes municipalities change levels of chemicals like chlorine without notifying dialysis centers.
Hemolysis can be fatal, doctors said, but it depends on the health of the patient.
The death believed linked to dialysis was that of an older man who was taken to North Arundel Hospital when he became ill. Because he was Muslim, his family does not want an autopsy. The man received dialysis at Bon Secours' Glen Burnie clinic. In the other death that may be linked to dialysis, an elderly patient who was passing through Baltimore and received a dialysis session later suffered a fatal heart attack at St. Agnes Hospital.
"So many patients have a multiplicity of problems. Without an autopsy and official cause of death, it's hard to say if it's a result [of the dialysis] or not," Law said. He noted that there may be other hemolysis cases that have gone undetected because the patients didn't get sick.
'Many more cases' predicted
"Once people start looking for it," Law said, "I think we'll find many more cases reported throughout the country."
Names of the Maryland dialysis patients, most of whom had been seen at Bon Secours, were not released. It was unclear how many remained hospitalized last night. One was discharged yesterday, Law said, and a few others are to be sent home today.
Roughly 200,000 Americans rely on dialysis because their kidneys no longer work, mostly as a result of diabetes, hypertension or a kidney condition. For a variety of reasons, their numbers are growing by about 7 percent to 9 percent a year. These patients are typically dialyzed about three times a week, for three to four hours. It costs about $45,000 annually to take care of one patient.
In 1995, one study found the country's total dialysis costs to be $13.1 billion, 75 percent of which is borne by the federal government through Medicare.
Dr. Paul J. Scheel, clinical director of nephrology at Johns Hopkins Hospital, directs the dialysis unit, which serves about 90 patients. He said what happened at Bon Secours is one of his biggest worries.
"We typically have so many backup systems in place that even if one were to fail, the other two or three would kick in," he said, noting that there have been only a few similar incidents nationally over the past 10 years.
One source of trouble, he said, is that some centers will reuse a dialysis cartridge on the same patient to save money, cleaning it out with formaldehyde between sessions. The cartridges, which cost from $13 to $50 each, act as the membrane that filters out impurities from the blood.
Both Hopkins and Bon Secours said they do not reuse the cartridges.
Pub Date: 5/25/98