FDA Adverse Event Malfunction Summary report: N

NI

MDR report key: 23476953 · Received November 5, 2025

Report

Report Number: 3030306055-2025-00455
Event Type: Malfunction
Date Received: November 5, 2025
Date of Event: October 9, 2025
Report Date: November 5, 2025
Manufacturer: VANTIVE US HEALTHCARE LLC
Product Code: FKX
PMA / PMN Number: NI
Product Problem: Yes
Report Source: Manufacturer report
Reporter Location: VA, US
Reporter Occupation: 003

Narratives

Additional Manufacturer Narrative · 0

G1: THE DEVICE WAS MANUFACTURED AT ONE OF THE FOLLOWING FACILITIES: VANTIVE HEALTHCARE - MOUNTAIN HOME 1900 N HIGHWAY 201 MOUNTAIN HOME AR 72653 UNITED STATES. VANTIVE HEALTHCARE - DOMINICAN REPUBLIC CARRETERA SANCHEZ KM 18.5 PARQUE INDUSTRIAL ITABO, PIISA HAINA, SAN CRISTOBAL 91000 DOMINICAN REPUBLIC. THE DEVICE WAS NOT RETURNED AND THE LOT NUMBER IS UNKNOWN; THEREFORE, A DEVICE ANALYSIS COULD NOT BE COMPLETED. SHOULD ADDITIONAL RELEVANT INFORMATION BECOME AVAILABLE, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.

Description of Event or Problem · 0

IT WAS REPORTED THAT THERE WAS A "BUBBLE" INSIDE A HOMECHOICE CASSETTE. THIS OCCURRED DURING LAST FILL OF THE PERITONEAL DIALYSIS THERAPY. THERE WAS NO REPORT OF PATIENT INJURY OR MEDICAL INTERVENTION ASSOCIATED WITH THIS EVENT. NO ADDITIONAL INFORMATION IS AVAILABLE.

Devices

Seq	Brand	Generic	Product Code	Manufacturer	Model	Lot	UDI-DI
2491499	NI	SYSTEM, PERITONEAL, AUTOMATIC DELIVERY	FKX	VANTIVE US HEALTHCARE LLC	NA	ASKU

Patients

Seq	Age	Sex	Outcome	Treatment
1	NA	Unknown		HOMECHOICE CLARIA