Laboratory and clinical physicians’ collaborative approach: two cases with intravascular haemolysis post dialysis

XXXIII. WASPaLM World Congress & XXIV. National Clinicial Biochemistry Congress, Antalya, Türkiye, 16 - 20 Ekim 2024, ss.81

Introduction: Haemolysis during dialyses may occur due to reasons such as water-borne toxins,

centralized dialysis equipment failure, blood tubing defects or from inadequate medical dialytic

therapy. Progression of this condition within patients is a severe life-threatening condition. Haemolysis

interference lead to incorrect laboratory results, hence, if this goes unnoticed, patients may be

misdiagnosed and treated incorrectly.

Case Presentation: In this case report, two female patients in their 70’s were admitted to our

emergency department within 6 months period, post their haemodialysis session from the same

dialysis centre. Case 1 applied with symptoms such as nausea, abdominal pain and vomiting. After a

while ecchymosis and icterus developed. On the other hand, Case 2 had similar symptoms with an

addition of sudden skin darkening. Following primary evaluation, Case 1 was referred to Internal

Medicine Intensive Care Unit with pre-diagnosis of thrombotic thrombocytopenic purpura. Case 2 was

referred to Gastroenterology department with pre-diagnosis of liver failure or cholestasis and ERCP

was considered. Both patients’ blood specimen was rejected due to high haemolysis index by

laboratory staff. However, after second blood specimens were evaluated by laboratory physician, in

vivo haemolysis was contemplated. Primarily, in vitro haemolysis reasons were eliminated and

clinicians were informed that the patients may have in vivo haemolysis, therefore the followings tests

were required; peripheral blood smear, reticulocyte count, Coombs test, haptoglobin and coagulation

test. Blood samples were tested using dilution factors to exclude interference caused by high

haemolysis index. Case 1 and Case 2 results respectively: Haemoglobin: 10.5 g/dL, 9.8 g/dL;

Reticulocyte count: 0.0542 106/uL, 0.0704 106/uL; Reticulocyte percentage: 1.89 %, 2.47%; Platelet

count: 82 103/uL, 148 103/uL; WBC count: 22.66 103/uL, 9 103/uL; Lactate dehydrogenase: 6980

U/L, 3279 U/L; Haptoglobin: 0,5 g/L, 0.5 g/L; Total bilirubin: 6.8 mg/dL, 2.4 mg/dL; Unconjugated

bilirubin: 5.4 mg/dL, not detected; AST: 770 U/L, 280 U/L ; ALT: 290 U/L, 90 U/L; Amylase <3 U/L,

150 U/L; Lipase 190 U/L, 349 U/L; for both cases Coombs test: Negative and Schistocytes: Not

detected. According to the assessment of both patients clinical follow up including variety of tests, in

vivo haemolysis was verified; pre-diagnose of thrombotic thrombocytopenic purpura and ERCP

procedure was eradicated for case 1 and 2 respectively.

Conclusion: In both cases, patients were treated and were discharged after their recovery. These case

examples demonstrate that pre-analytical factors such as haemolysis affect laboratory results and

laboratory physicians must be aware of these possible faulty interferences. Thus, importance of

collaborative work between clinicians and laboratory physicians is highly important to obtain the

optimum outcome for patients.

Keywords: Intravascular Haemolyses, Dialysis, Interdisciplinary Communication