Forensic Science, Medicine, and Pathology

, Volume 8, Issue 3, pp 259–262 | Cite as

Fatal exsanguination from hemodialysis vascular access sites

  • James R. Gill
  • Kara Storck
  • Sean Kelly
Original Article


Exsanguination from hemodialysis vascular sites may cause a rapid death. Due to extensive blood loss at the scene, investigators may initially suspect a homicide or suicide. We reviewed 100 deaths due to hemorrhage from hemodialysis shunt sites. The majority (81%) of these hemorrhages occurred at home and 44% subsequently died at home. Recognition of this medical complication at the scene is important to prevent the dispatch of the crime scene or homicide unit. In these instances, the common causes of kidney failure included hypertensive cardiovascular disease and diabetes mellitus. The manners of death were certified as therapeutic complication (93%), accident (5%), and suicide (2%). These fatal shunt hemorrhages are rapid and large due to their superficial subcutaneous locations and elevated shunt pressures from the arterial-venous anastamosis. The cause of death statement must include the proximate cause of death, which is usually the disease that resulted in kidney failure, if it is known.


Forensic science Forensic pathology Hemodialysis Shunt Exsanguination Fatality 


  1. 1.
    Nassar GM, Ayus JC. Infectious complications of the hemodialysis access. Kidney Int. 2001;60:1–13.PubMedCrossRefGoogle Scholar
  2. 2.
    Himmelfarb J. Hemodialysis complications. Am J Kidney Dis. 2005;45:1122–31.PubMedCrossRefGoogle Scholar
  3. 3.
    Cohle SD, Graham MA. Sudden death in hemodialysis patients. J Forensic Sci. 1985;30:158–66.PubMedGoogle Scholar
  4. 4.
    Karnik JA, Young BS, Lew NL, Herget M, Dubinsky C, Lazarus JM, et al. Cardiac arrest and sudden death in dialysis units. Kidney Int. 2001;60:350–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Winsett OE, Wolma FJ. Complications of vascular access for hemodialysis. South Med J. 1985;78:513–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Wong JK, Sadler DJ, McCarthy M, Saliken JC, So CB, Gray RR. Analysis of early failure of tunneled hemodialysis catheters. AJR Am J Roentgenol. 2002;179:357–63.PubMedGoogle Scholar
  7. 7.
    Berger EE, Lowrie EG. Mortality and the length of dialysis. Jama. 1991;265:909–10.PubMedCrossRefGoogle Scholar
  8. 8.
    Byard RW, James RA. Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites. Forens Sci Med Pathol. 2007;3:128–32.CrossRefGoogle Scholar
  9. 9.
    Bourgoignie J, Pardo V. The nephropathology in human immunodeficiency virus infection (HIV). Kidney Int. 1991;40(suppl 35):S19–23.Google Scholar
  10. 10.
    Gill JR, Goldfeder LB, Hirsch CS. Use of “therapeutic complication” as a manner of death. J Forensic Sci. 2006;51:1127–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Robinson BM, Joffe MM, Berns JS, Pisoni RL, Port FK, Feldman HI. Anemia and mortality in hemodialysis patients: accounting for morbidity and treatment variables updated over time. Kidney Int. 2005;68:2323–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Vaziri ND, Toohey J, Paule P, Alikhani S, Hung E. Coagulation abnormalities in patients with end-stage renal disease treated with hemodialysis. Int J Artif Organs. 1984;7:323–6.PubMedGoogle Scholar
  13. 13.
    Adams VI, Flomenbaum MA, Hirsch CS. Trauma and disease. In: Spitz W, editor. Spitz and Fisher’s medicolegal investigation of death. Springfield: Charles C Thomas; 2006. p. 436–59.Google Scholar
  14. 14.
    Marc B, Baudry F, Zerrouki L, Ghaith A, Garnier M. Suicidal incised wound of a fistula for hemodialysis access in an elderly woman: case report. Am J Forensic Med Pathol. 2000;21:270–2.PubMedCrossRefGoogle Scholar
  15. 15.
    deRoux S. Suicidal incised wound of a fistula for hemodialysis access in an elderly woman. Am J Forensic Med Pathol. 2001;22:212–3.PubMedCrossRefGoogle Scholar
  16. 16.
    Siedlecki A, Barker J, Allon M. Aneurysm formation in arteriovenous grafts: associations and clinical significance. Semin Dial. 2007;20:73–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Brattich M. Vascular access thrombosis: etiology and prevention. ANNA J. 1999;26:537–40.PubMedGoogle Scholar
  18. 18.
    Bone GE, Pomajzi MJ. Management of dialysis fistula thrombosis. Am J Surg. 1979;138:901–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.New York City Office of Chief Medical ExaminerNew YorkUSA
  2. 2.Department of Forensic MedicineNew York University School of MedicineNew YorkUSA

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