LIVER-FAILURE AND DEATH AFTER EXPOSURE TO MICROCYSTINS AT A HEMODIALYSIS CENTER IN BRAZIL

Background Hemodialysis is a common but potentially hazardous procedur e. From February 17 to 20, 1996, 116 of 130 patients (89 percent) at a dialysis center (dialysis center A) in Caruaru, Brazil, had visual di sturbances, nausea, and vomiting associated with hemodialysis. By Marc h 24, 26 of the patients had died of acute liver failure. Methods A ca se patient was defined as any patient undergoing dialysis at dialysis center A or Caruaru's other dialysis center (dialysis center B) during February 1996 who had acute liver failure. To determine the risk fact ors for and the source of the outbreak, we conducted a cohort study of the 130 patients at dialysis center A and the 47 patients at dialysis center B, reviewed the centers' water supplies, and collected water, patients' serum, and postmortem liver tissue for microcystin assays. R esults One hundred one patients (all at dialysis center A) met the cas e definition, and 50 died. Affected patients who died were older than those who survived (median age, 47 vs. 35 years; P<0.001). Furthermore , all 17 patients undergoing dialysis on the Tuesday-, Thursday-, and Saturday-night schedule became ill, and 13 of them (76 percent) died. Both centers received water from a nearby reservoir. However, the wate r supplied to dialysis center B was treated, filtered, and chlorinated , whereas the water supplied to dialysis center A was not. Microcystin s produced by cyanobacteria were detected in water from the reservoir and from dialysis center A and in serum and liver tissue of case patie nts. Conclusions Water used for hemodialysis can contain toxic materia ls, and its quality should therefore be carefully monitored. (C) 1998, Massachusetts Medical Society.