MAUDE Adverse Event Report: NIPRO CORPORATION USD EXELTRA; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM

Catalog Number	5M2120
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Should additional relevant information become available, a supplemental report will be submitted.
Event or Problem Description
It was reported that there were four (4) instances where some blood was oozing around the connection of the dialyzer to the blood lines.This occurred with the same patient.There was no patient injury or medical intervention associated with this event.No additional information is available.
Additional Manufacturer Narrative
The devices were not received for evaluation; therefore, device analysis could not be completed.A batch review was conducted and there were no deviations found related to this reported condition during the manufacture of this lot.A retention sample was evaluated and it was found to be within all product specifications.The reported event was not verified.Should additional relevant information become available, a supplemental report will be submitted.

• Brand Name: EXELTRA
• Common Device Name: DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
• Manufacturer (Section D): NIPRO CORPORATION USD; ohdate-shi
• MDR Report Key: 7548807
• Report Number: 1416980-2018-03213
• Device Sequence Number: 16214372
• Product Code: KDI
• UDI-Device Identifier: 00085412071213
• UDI-Public: (01)00085412071213
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K030974
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 07/20/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2019
• Device Catalogue Number: 5M2120
• Device Lot Number: 17A23E
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/02/2018
• Supplement Date Received by Manufacturer: 07/17/2018
• Initial Report FDA Received Date: 05/29/2018
• Supplement Report FDA Received Date: 07/20/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1