FDA Adverse Event Death Summary report: N

NATURALYTE 2251 2K 2.5CA

MDR report key: 4741798 · Received April 30, 2015

Report

Report Number
1225714-2015-02367
Event Type
Death
Date Received
April 30, 2015
Report Date
April 3, 2015
Manufacturer
FRESENIUS MEDICAL CARE NORTH AMERICA
Product Code
KPO
PMA / PMN Number
K981043
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Occupation
NOT APPLICABLE

Narratives

Additional Manufacturer Narrative · 1

AMERICAN JOURNAL OF KIDNEY DISEASE 2015. ARTICLE IN PRESS, ADRIANNA M. HUNG, MD, MPH AND RAYMOND M. HAKIM, MD, PHD. DIALYSATE AND SERUM POTASSIUM IN HEMODIALYSIS. PUBLISHED BY ELSEVIER, INC. ON BEHALF OF THE NATIONAL KIDNEY FOUNDATION. THIS REPORT IS BEING SUBMITTED AS PART OF A SYSTEM LEVEL REVIEW; WHICH WILL INCLUDE AN INVESTIGATION OF ALL POTENTIAL FRESENIUS PRODUCTS BEING USED AT THE TIME OF THE EVENT. A SUPPLEMENTAL REPORT WILL BE SUBMITTED UPON COMPLETION OF THE PLANT'S INVESTIGATION.

Description of Event or Problem · 1

AMERICAN JOURNAL KIDNEY DISEASE 2015: "A (B)(6) MAN WITH END STAGE RENAL DISEASE SECONDARY TO LONG STANDING HYPERTENSION WAS UNDERGOING HIS USUAL DIALYSIS TREATMENT WHEN HE EXPERIENCED SUDDEN CARDIAC ARREST DURING THE SECOND HALF OF THE DIALYSIS TREATMENT... UNFORTUNATELY, THE PATIENT DID NOT RESPOND TO CARDIAC RESUSCITATION MANEUVERS AND DIED." THE PATIENT'S TREATMENT LENGTH WAS 3.5 HOURS; DIALYSATE POTASSIUM CONCENTRATION, 2 MEQ/L (K2); CALCIUM CONCENTRATION, 2.5 MEQ/L; AND BICARBONATE CONCENTRATION, 39 MEQ/L (THE BICARBONATE BATH WAS FROM A CONCENTRATE MIX THAT ALSO HAD 8 MEQ/L OF ACETATE, RESULTING IN A TOTAL BUFFER OF 47 MEQ/L). HIS INTERDIALYTIC WEIGHT GAIN WAS AN AVERAGE OF 4 TO 4.2 KG. NECESSITATING AN ULTRAFILTRATION RATE OF W15 ML/KG/H TO ACHIEVE HIS DRY WEIGHT OF 77 KG. HIS PHYSICAL EXAMINATION FINDINGS WERE UNREMARKABLE. HIS MEDICAL HISTORY INCLUDED LEFT VENTRICULAR HYPERTROPHY AND DIASTOLIC HEART FAILURE, WHICH HAD BEEN CONTROLLED SINCE THE INITIATION OF DIALYSIS THERAPY.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
283302 NATURALYTE 2251 2K 2.5CA KPO FRESENIUS MEDICAL CARE NORTH AMERICA

Patients

Seq Age Sex Outcome Treatment
1 68 YR Death NATURALYTE BICARBONATE| OPTIFLUX 200A DIALYZER