Symptomatic hypocalcemia due to the inadvertent use of a calcium-free hemodialysate.

Hemodialysis using a bath with less-than-normal calcium level can cause hypocalcemia. The development of symptomatic hypocalcemia with resultant hypotension after the inadvertent use of a calcium-free dialysate in a maintenance hemodialysis patient is described. It is suggested that the occurrence of similar mishaps in the future can be reduced by close checking of dialysate concentrate labels.