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    Complications of Hemodialysis: DR Ashok Bhat Consultant Nephrologist KMC Hospital Ambedkar Circle Mangalore

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    Dani Dany
    Common complications of hemodialysis include hypotension, cramps, nausea and vomiting, and headache. Hypotension is the most common complication and can be caused by factors like excessive fluid removal, medications, or underlying cardiac issues. Other complications discussed are intradialytic hypertension, cardiac arrhythmias, fever and chills, muscle cramps, and rare but serious issues like dialysis disequilibrium syndrome and air embolism.

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    Complications of Hemodialysis: DR Ashok Bhat Consultant Nephrologist KMC Hospital Ambedkar Circle Mangalore

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    Dani Dany
    14 views32 pages
    Common complications of hemodialysis include hypotension, cramps, nausea and vomiting, and headache. Hypotension is the most common complication and can be caused by factors like excessive fluid removal, medications, or underlying cardiac issues. Other complications discussed are intradialytic hypertension, cardiac arrhythmias, fever and chills, muscle cramps, and rare but serious issues like dialysis disequilibrium syndrome and air embolism.

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    Hemodialysis complications

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    Common complications of hemodialysis include hypotension, cramps, nausea and vomiting, and headache. Hypotension is the most common complication and can be caused by factors like excessive fluid removal, medications, or underlying cardiac issues. Other complications discussed are intradialytic hypertension, cardiac arrhythmias, fever and chills, muscle cramps, and rare but serious issues like dialysis disequilibrium syndrome and air embolism.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    14 views32 pages

    Complications of Hemodialysis: DR Ashok Bhat Consultant Nephrologist KMC Hospital Ambedkar Circle Mangalore

    Uploaded by

    Dani Dany
    Common complications of hemodialysis include hypotension, cramps, nausea and vomiting, and headache. Hypotension is the most common complication and can be caused by factors like excessive fluid removal, medications, or underlying cardiac issues. Other complications discussed are intradialytic hypertension, cardiac arrhythmias, fever and chills, muscle cramps, and rare but serious issues like dialysis disequilibrium syndrome and air embolism.

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    Complications of Hemodialysis

    Dr Ashok Bhat
    Consultant Nephrologist
    KMC Hospital
    Ambedkar circle
    Mangalore
    Common Complications
    • Hypotension – 25 to 55 percent of treatments
    • Cramps – 5 to 20 percent
    • Nausea and vomiting – 5 to 15 percent
    • Headache – 5 percent
    • Chest pain – 2 to 5 percent
    • Back pain – 2 to 5 percent
    • Itching – 5 percent
    • Fever and chills – <1 percent
    • Bregman H, Daugirdas JT, Ing TS. Complications during hemodialysis. In: Handbook of Dialysis, Dauugirdas JT, Ing TS (Eds), Little, Brown, New York 1994. p.149.
    Hypotension
    • Definition :
    • A decrease in SBP > 20 mmHG or a decrease in MABP >10 mmHg
    associated with symptoms that include abdominal discomfort ,
    yawning , sighing , nausea , vomiting , restlessness , cramps , dizziness
    or fainting and anxiety . KDOQI 2002

    • A decrease of SBP> 20mmHG or a decrease in MABP >10 mmHg


    associated with clinical events or need for nursing interventions EBPG2007
    Most common complication
    Intradialytic Hypotension : causes

    • Patient related • Procedure related


    • Excessive fluid removal (>1.5 l/ h)
    • Cardiac causes
    • High dialysate temperature
    • Autonomic dysfunction
    • Dialysate composition
    • Severe anaemia
    Low Na < 138
    • Food intake
    Low Ca
    • Antihypertensive medications Acetate dialysate
    • Sepsis • Hemorrhage
    • High interdialytic weight gain • Hemolysis
    • Air embolism
    • Dialyzer reaction
    Intradialytic Hypotension : acute managment
    • Decrease UF / stop UF

    • Trendlenberg position

    • Fluid bolus 200-250 ml – saline , hypertonic glucose

    • Oxygen

    • Persistent hypotension despite above measures – likely to have some serious


    underlying cause – stop dialysis and assess the cause
    Intradialytic Hypotension : prevention of
    recurrent episodes
    • Reassess Target weight
    Trial and error “probing method”- most common
    Bioimpedance AJKD 2013
    Blood volume measurement KI 2002
    • Avoid food intake during dialysis EBPG NDT 2007
    • Withold antihypertensives
    • Limit Interdialytic sodium intake – 2.5-5 gm salt(1/2tsp) / day
    Intradialytic Hypotension : prevention of
    recurrent episodes
    • Review dialysate composition
     Ca > 2.25 meq/l Mg > 1 meq/ l
    Na profiling – no definite benefit , may increase thirst and weight gain

    • Increase urine output


    Oral diuretics – in patients with RRF
    Reduce interdialytic weight gain – less need for UF
    Intradialytic Hypotension : prevention of
    recurrent episodes
    • Assess primary cardiac factors
    ECHO

    • Use of cool dialysate


    Emperic fixed reduction by 0.5-1°C
    Isothermic dialysis- sensor based reduction of dialysate temp
    as core body temperature increases JASN 2016

    • Increase dialysis time


    Intradialytic Hypotension : prevention of
    recurrent episodes
    • Midodrine – 2.5 -5 mg given 15-30 min before HD

    • Change to other modalities of dialysis


    CAPD
    Daily nocturnal HD
    Hemodiafiltration

    • Correction of Anaemia with EPO


    Headache
    • Definition (ICHD criteria)
    • A. At least three episodes of acute headache fulfilling the criteria
    • B. The patient is undergoing hemodialysis
    • C. Causal evidence is shown through at least two of the following:
    • 1. Each headache episode starts during hemodialysis
    • 2. One or both of the following:
    • a. Each headache episode worsens during hemodialysis
    • b. Each headache attack is resolved within 72 hours after finishing
    hemodialysis
    • 3. The headache episodes disappear after successful kidney transplant and
    the end of hemodialysis
    Headache : causes
    • Caffeine withdrawal (removed during dialysis)
    • Acetate dialysate
    • Intradialytic hypotension
    • Intradialytic hypertension
    • High calcium or magnesium in dialysate
    • Fluoride intoxication (contaminated dialysate)
    • Chloramine intoxication (contaminated dialysate)

    Rule out DDS and Hypertensive encephalopathy IC bleed


    Headache : Treatment
    • Acute : Paracetamol
    • Prevention : is a headache for the
    physician
    Bicarbonate dialysate
    Slow dialysis with reduced blood
    flow rates
    Sodium profile
    Ultrafiltration profile
    Coffee ingestion during dialysis
    Use of reprocessed dialyzers
    Shift to CAPD
    Frequently results in short HD
    Intradialytic Hypertension
    • Definition :
     Intradialytic increase in the SBP > 10 mmHg or MABP > 15 mmHg.
    Develops during the second or third hour of hemodialysis after
    significant ultrafiltration has taken place.
    Increase in the blood pressure is characterized as being resistant to
    ultrafiltration.
    Can be asymptomatic or can have acute headache , vomiting and
    sometimes result in a CVA
    Associated with increased mortality
    Intradialytic Hypertension
    • Treatment
    In seriously ill patients – Admission and parenteral medications
    Mildly symptomatic / asymptomatic – use oral BP medications
    • Prevention
    Adjust dry weight
    Dietary sodium restriction
    Adjust dialysate sodium to minimize intradialytic sodium gain
    Adjust dialysate potassium to avoid hypokalemia as it might induce vasoconstriction
    Use non-dialyzable anti-hypertensive drugs
    Do not hold anti-hypertensive drugs before dialysis
    Decrease erythropoietin dose if pre-dialysis hemoglobin is higher than 11 g/Dl
    Consider frequent (short daily or nocturnal) hemodialysis if hypertension remains resistant to
    preventive therapies
    Cardiac Arrhythmias
    • Can cause Hypotension , palpitations , anxiety
    • Responsible for majority of cases of Sudden cardiac death in
    Hemodialysis unit
    • Suspect in
    Patients complaining of palpitations
    Hypotension not responding to routine measures
    • Confirmation needs ECG
    • Treatment – depends on the type of arrhythmia
    • Avoid nil / low K dialysate and high Ca
    Fever Chills and Dyspnoea ?
    • Causes
    • Infections
    Vascular access
    Respiratory / other

    • Cold dialysate

    • Pyrogenic reaction
    Endotoxin contamination of dialysate
    • Drug Allergy
    • Hemolysis
    • Dialyzer reaction
    Fever Chills and Dyspnoea ?
    • Clinical assessment
    • Onset – before / after initiation of dialysis
    • Pus at exit site of catheter / at av fistula puncture site
    • History of medication administration during HD
    • Dark colour of blood in tubing – may suggest hemolysis
    • Hypotension
    Fever Chills and Dyspnoea ?
    • Management
    Depends on underlying cause
    May require stopping of dialysis
    Administration of antibiotics
    Removal of infected catheter
    Adrenaline / corticosteroids – for anaphylactic reaction
    Muscle cramps
    • Associated with excessive UF

    • Frequently accompanied with vomiting and hypotension

    • Stop UF

    • Administer NS , 3%saline , Hypertonic Dextrose

    • Reassess dry weight

    • Na modelling
    Rare but serious complications
    • Dialysis disequilibrium syndrome

    • Air embolism

    • Hemolysis

    • Allergic reaction

    • Vascular access hemorrhage

    • Venous needle dislodgement


    Dialysis Disequilibrium syndrome
    Risk factors
     First dialysis
     High BUN >175 mg/dl
     Hyponatremia
     Chronic liver disease
     Traumatic brain injury

    Prevention
     Limit 1st session to 2-2.5 hrs
     Blood flow 200 ml/min – aim URR < 0.4
    Symptoms  Sodium modelling / high sodium
    Mild  IV mannitol
     Nausea , vomiting , headache  CRRT for high risk ( Cerebral trauma , mass , ic bleed)
    Severe
     Seizure , decerebration , coma
    Air Embolism
    • Rare but potentially fatal (100-300 ml air is fatal)
    • ABD clamps in modern HD machines have practically eliminated this complication
    • Air entry entirely due to healthcaregivers error
    • Air entry to circuit should trigger the ABD and the dialysis stops immedieatly.
    • Air enters patient only if ABD is bypassed by technician.Can happen during priming
    and during end and return of blood at end of HD.
    • Portals of air entry
    Inadequate flushing of air during priming
    Arterial port of dialysis catheters – esp when there is poor flow relative to pump
    speed
    Saline or heparin pump
    During Dialysis catheter removal
    Air Embolism
    • Symptoms – depend on amount, speed, and site of introduced air, & patient’s position

    • Sitting position – venous emboli in cerebral circulation


    Seizure, coma
    • Supine position
     Impaired right ventricular function (decreased cardiac output and hypotension)
     Microemboli to pulmonary vasculature (dyspnea, dry cough, chest tightness or
    pain, hypoxia, respiratory failure)
     Sudden cardiac arrest (> 50 mL)

    • Left trendelenburg position


    Lower extremity venous occlusion, and arterial ischemia from increased outflow
    resistance.
    Air Embolism : Management
    • Diagnosis – clinical suspicion , foam in circuit
    • Treatment
    Clamp venous blood line
    Stop blood pump
    Place patient in the left Trendelenburg position
    Cardiovascular support
    High flow oxygen administration
    Endotracheal intubation
    Mechanical ventilation
    Aspirate air from right ventricle using percutaneously-inserted needle or right atrial dialysis
    catheter
    Consider hyperbaric oxygenation treatment if available
    Hemolysis • Symptoms
    • Causes
    • Dialysate related Nausea vomiting
    Contamination with copper , chlorine ,
    chloramine,zinc , nitrate ,nitrite,hydrogen
    peroxide , formaldehyde Abdominal / chest pain
    Hyposmolar dialysate
    Hyperthermia Shortness of breath
    • Extracorporeal circuit related
    Blood pump malocclusion
    Hypertension
    Kinked tubing
    Partial occlusion of HD catheter
    • Patient related Change of colour (darkening)of blood in
    Sickle cell anaemia
    tubing
    Heriditary spherocytosis
    Autoimmune hemolytic anaemia Multiple patients affected simultaneously
    Hemolysis Managment
    Venous needle dislodgement
    • Rare but potentially fatal
    • Massive blood loss can occur in a few minutes
    • Dislodgment should ideally trigger venous pressure alarm and stop
    blood pump
    • Failure to trigger this is due to wide venous pressure alarm limits set
    to prevent false alarms!
    • Poor staff to patient ratio also contributes to oversight
    • Improper taping of fistula needle , failure to provide adequate free
    loop,loose luer lock connection , site not kept visible are risk factors
    • Confused / delirious patient pulling the needle
    Prevention of VND
    Vascular access Hemorrhage
    • Due to aneurysm rupture
    • Avoid cannulating aneurysms
    • Signs of imminent rupture –
    thinning and redness of skin,rapid
    enlargement,outflow stenosis ,
    infection
    • Inform Nephrologist / surgeon
    • Bleed to be managed with direct
    local pressure till help of vascular
    surgeon is available
     Despite Precautions adverse effects do occur
    during HD
     Do not blame each other during an adverse
    event- work as a team to manage the acute
    event
     Keep a diligent record of adverse events in
    your unit – It will help you to prevent further
    such episodes
     Have a Protocol based approach – it will
    reduce the adverse events
     Maintain proper nurse to patient ratio

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