The Maryland medical examiner's office has called attention to the cases of 24 kidney dialysis patients who bled to death, usually at home alone, prompting health agencies to alert dialysis centers and patients to take precautions.
Dr. David Fowler, the state's chief medical examiner, said the cases of 22 people who died at home and two others who died at dialysis centers since 2000 came to light after he noticed a cluster and asked his staff to review records. A regional coalition of kidney programs said it is aware of 38 deaths over the six-year period.
FOR THE RECORD - An article in yesterday's editions incorrectly reported that almost 12,000 people on dialysis die annually in Maryland. In fact, that figure represents deaths between Jan. 1, 2000, and Aug. 8, 2006, according to the Mid-Atlantic Renal Coalition.
THE SUN REGRETS THE ERROR
In dialysis, a lifesaving treatment for kidney disease, a patient's blood is cycled through a machine that removes impurities and waste products. In most cases, doctors tap a vein in the arm or leg, creating a "vascular access site" or portal that can be used for years.
Most of the people died after their access sites weakened from repeated use and finally leaked.
"Most of these people seemed to be alone at the time the bleeding occurred," Fowler said in an interview. "Nobody was there to assist them."
The patients were as young as 28 and as old as 85. Almost two-thirds were men, and three-quarters were African-Americans. Kidney disease disproportionately affects blacks, who account for a third of people with kidney failure, according to the National Institutes of Health.
It remains unclear whether the number of deaths in Maryland was unusual. Fowler said he was hoping to invite discussion and possibly some answers when a research fellow, Dr. Donna Vincenti, presents the data next month at a national forensics conference. They also plan to submit an article to a national medical journal for publication.
Fowler, who declined to make public the names of patients who died or their dialysis centers, said the cases were scattered across the state.
Three agencies joined last month in issuing advisories to dialysis centers that treat up to 20,000 Marylanders.
"Some deaths from vascular access hemorrhage may have been preventable," the advisory reads. Patients should have "repeated educational sessions" about the proper care of their access sites and the signs of trouble.
A flier intended for distribution to patients lists warning signs such as redness, swelling, fever, chills and the loss of vibration - called "thrill" - when fingers are placed on the skin over the access site. Patients are advised to contact their dialysis centers if anything appears wrong, and to apply firm pressure and call 911 if they start bleeding.
Issuing the alerts were the Baltimore and state health departments and the Maryland Kidney Commission, which certifies and sets standards for dialysis centers and handles patient complaints. Fowler presented his findings to the commission last month.
The state health department found no evidence of insufficient care, a top official said.
"It wasn't a fault issue," said Wendy Kronmiller, director of the state Office of Health Care Quality. "It's just such a gruesome outcome, we wanted to make sure the message got out."
The Mid-Atlantic Renal Coalition, which oversees kidney programs in three states and the District of Columbia, knew of more cases than Fowler did. But the medical examiner said some cases might not have been referred for autopsy if the cause of death was obvious.
Nancy Armistead, director of the coalition, said she did not agree that the number was high enough to justify the health alerts.
"It's over a fairly long time period, and it's a relatively small number of deaths," she said. But she said, "I agree that some of these might be preventable."
Putting the deaths in context, she said, almost 12,000 dialysis patients die every year in Maryland.
Armistead said the bleeding deaths represented about three-tenths of 1 percent of all dialysis deaths in Maryland - slightly higher than in West Virginia, and slightly less than in Virginia or Washington. Nationally, the leading causes of deaths among dialysis patients are cardiovascular disease and a patient's decision to discontinue dialysis treatments.
"Every death is significant, but statistically we didn't think it was anything that warranted the kind of attention the medical examiner is giving it," she said, adding that the coalition doesn't have the resources to pursue the issue.
Dr. Joshua Sharfstein, Baltimore's health commissioner, said the numbers were "striking" enough to justify a public health alert. "If there's something simple we could be doing to reduce the chance of a catastrophic outcome, then we should be doing that."
Patients usually get three dialysis treatments a week and may continue for years. In the dialysis center, a staffer inserts a needle into an access site in the patient's forearm or leg. The patient's blood is then diverted through plastic tubing to a filter before being returned to the body.