Severe metabolic acidosis during haemodialysis: a rare but life threatening complication.

Dialysis fluids are real ‘drugs’ and as a consequence they need pharmacological preparation in order to meet the criteria of quality and standarization. Modern dialysis machines permit accurate proportioning of treated water and salts and also guarantee a continuous monitoring of the accuracy of the final composition and maintenance of the desired proportions. However, errors with dialysate concentrations are numerous and may go underdetected as causes of morbidity and mortality in patients undergoing haemodialysis (HD) w1x. Two cases of severe metabolic acidosis as complications of HD have been recorded in two dialysis units, which have been dialysing more than 50 patients daily during the last 5 years. Early recognition and proper treatment resulted in favourable outcome.