Dialysis complications: Difference between revisions

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==Hypotension==
==Background==
===Background===
*Dialysis patients are high-acuity ED patients with unique complications
#Most frequent complication of hemodialysis, occurring during 20% to 30% of treatments
*Common presentations: access problems, hypotension, electrolyte emergencies, infections
#Timing of intradialytic hypotension is helpful in formulating DDX:
*Always check when last dialysis session was and if any were missed
##Hypotension early in session usually due to preexisting hypovolemia
##Hypotension during the session is often due to blood loss (from tubing or filter leak)
##Hypotension near the end usually result of excessive ultrafiltration
###Underestimation of pt's ideal blood volume (dry weight)
###Also consider pericardial or cardiac disease


===Clinical Features===
==Hemodialysis Complications==
#N/V
{{Dialysis complications DDX}}
#Anxiety
#Dizziness
#Orthostatic hypotension
#Syncope


===Diagnosis===
===Access Complications===
#Assess:
{{AV shunt complications DDX}}
##Volume status (US)
*Thrombosed fistula/graft: absent thrill/bruit → vascular surgery referral within 24-48h
##Cardiac function
*Hemorrhage from access site: direct pressure x 10-15 min; avoid tourniquet proximal to access
##Pericardial disease
*Infection: erythema, warmth, purulent drainage → blood cultures + empiric [[vancomycin]]; avoid using infected access
##Infection
*Steal syndrome: hand ischemia distal to fistula (pain, pallor, cool fingers) → vascular surgery
##GI bleeding


===DDX===
===During/Post-Dialysis===
#Excessive ultrafiltration
*Hypotension: most common acute complication; give NS bolus (avoid excessive fluid in volume-overloaded patient)
#Predialytic volume loss
*[[Dysequilibrium syndrome]]: headache, N/V, AMS, seizures during/after dialysis (especially first sessions) — diagnosis of exclusion after ruling out other AMS causes
##GI losses
*Air embolism: rare but catastrophic; place in left lateral decubitus/Trendelenburg
##Decreased oral intake
*Muscle cramps: NS bolus, reduce ultrafiltration rate
#Intradialytic volume loss
##Tube and hemodialyzer blood losses
#Postdialytic volume loss
##Vascular access blood loss
#Medication effects
##Antihypertensives
##Opiates
#Decreased vascular tone (sepsis)
#Cardiac dysfunction
##LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
#Pericardial disease
##Effusion
##Tamponade


==Dialysis Disequilibrium Syndrome==
===Missed Dialysis===
###Clinical syndrome occurring at end of dialysis
*'''[[Hyperkalemia]]''': most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
###Characterized by N/V, HTN (can progress to seizure, coma, death)
*Volume overload / [[pulmonary edema]]: BiPAP, [[nitroglycerin]], [[furosemide]] (limited efficacy in anuric patients), emergent dialysis
###Large solute clearances -> cerebral edema
*[[Uremic pericarditis]]: friction rub, emergent dialysis; avoid anticoagulation (hemorrhagic risk)
####Occurs most commonly during initial dialysis or during hypercatabolic states
*Metabolic acidosis
###Treatment
####Mannitol


==Air Embolism==
==Peritoneal Dialysis Complications==
###Acute dyspnea, chest tightness, LOC, cardiac arrest
*[[Peritoneal dialysis-associated peritonitis]]: cloudy effluent, abdominal pain, fever
###Treatment
**Send peritoneal fluid for cell count, Gram stain, culture
####100% NRB
**Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
*Catheter malposition, obstruction, leakage
*Exit site/tunnel infection: erythema, drainage at catheter site


==Vascular Access Complications==
==Altered Mental Status in Dialysis Patients==
===Thrombosis and Stenosis===
*[[Hypotension]]
#Most common causes of inadequate dialysis flow
*[[Hypoglycemia]]
##Loss of bruit and thrill over access
*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
#Stenosis and even thrombosis are not emergencies
*[[Subdural hematoma]] (from anticoagulation during dialysis)
##Can be treated w/in 24hr by angiographic clot removal or angioplasty
*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
##Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg ###This therapy should be discussed with the vascular surgeon first
*[[Stroke]]
===Vascular Access Infection===
*[[Uremia]] (inadequate dialysis)
#Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
*Medication accumulation (renally cleared drugs)
##Classic signs of pain, erythema, swelling, d/c from infected access are often missing
*Sepsis
#Dialysis catheter–related bacteremia is common and potentially life-threatening
##Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
##Do not remove dialysis patient's access
#Draw peripheral and catheter blood cultures simultaneously
##4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
###Even so catheter is only removed if fever persists for 2-3d after abx are started
===Hemorrhage===
#Potentially life-threatening
#Can result from aneurysms, anastomosis rupture, or over-anticoagulation
#Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
#Types
##Aneursym (true)
###Most are asymptomatic; rarely rupture
##Pseudoaneurysm
###Result from subcutaneous extravasation of blood from puncture sites
###Bleeding from puncture site is usually controlled by digital pressure or subq suture
###Consider vascular surgery consultation for continued bleeding or infection
###Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
===Vascular insufficiency===
#Distal extremity becomes ischemic due shunting of arterial blood to venous side
##Exercise pain, nonhealing ulcers, cool, pulseless digits
##Diagnosed by Doppler US or angiography, repaired surgically
===High-output heart failure===
#Occurs when >20% of cardiac output is diverted through the access
##Branham sign (drop in HR after temporary access occlusion) is diagnostic
##Doppler US can accurately measure access flow rate and establish the diagnosis ##Surgical banding of the access is treatment of choice


==Source==
{{ESRD Associated Skin Conditions}}
Tintinalli


[[Category:Nephro]]
==Evaluation==
*[[ECG]] (hyperkalemia changes — peaked T waves, widened QRS)
*[[BMP]]: K, Ca, BUN, Cr, glucose
*[[CBC]], blood cultures if febrile
*[[CXR]]: pulmonary edema, line placement
*Access exam: check thrill/bruit
 
==Disposition==
*Low threshold for admission — these are high-risk patients
*Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
*Arrange emergent dialysis for: severe hyperkalemia, pulmonary edema, uremic pericarditis
*Discharge only for minor issues with ensured follow-up at dialysis center
 
==See Also==
*[[Hyperkalemia]]
*[[Peritoneal dialysis-associated peritonitis]]
*[[Chronic kidney disease]]
 
==References==
<references/>
 
[[Category:Renal]]
[[Category:Vascular]]

Latest revision as of 09:36, 22 March 2026

Background

  • Dialysis patients are high-acuity ED patients with unique complications
  • Common presentations: access problems, hypotension, electrolyte emergencies, infections
  • Always check when last dialysis session was and if any were missed

Hemodialysis Complications

Dialysis Complications

Access Complications

AV Fistula Complications

During/Post-Dialysis

  • Hypotension: most common acute complication; give NS bolus (avoid excessive fluid in volume-overloaded patient)
  • Dysequilibrium syndrome: headache, N/V, AMS, seizures during/after dialysis (especially first sessions) — diagnosis of exclusion after ruling out other AMS causes
  • Air embolism: rare but catastrophic; place in left lateral decubitus/Trendelenburg
  • Muscle cramps: NS bolus, reduce ultrafiltration rate

Missed Dialysis

  • Hyperkalemia: most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
  • Volume overload / pulmonary edema: BiPAP, nitroglycerin, furosemide (limited efficacy in anuric patients), emergent dialysis
  • Uremic pericarditis: friction rub, emergent dialysis; avoid anticoagulation (hemorrhagic risk)
  • Metabolic acidosis

Peritoneal Dialysis Complications

  • Peritoneal dialysis-associated peritonitis: cloudy effluent, abdominal pain, fever
    • Send peritoneal fluid for cell count, Gram stain, culture
    • Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
  • Catheter malposition, obstruction, leakage
  • Exit site/tunnel infection: erythema, drainage at catheter site

Altered Mental Status in Dialysis Patients

ESRD Associated Skin Conditions

Cardiovascular

Evaluation

  • ECG (hyperkalemia changes — peaked T waves, widened QRS)
  • BMP: K, Ca, BUN, Cr, glucose
  • CBC, blood cultures if febrile
  • CXR: pulmonary edema, line placement
  • Access exam: check thrill/bruit

Disposition

  • Low threshold for admission — these are high-risk patients
  • Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
  • Arrange emergent dialysis for: severe hyperkalemia, pulmonary edema, uremic pericarditis
  • Discharge only for minor issues with ensured follow-up at dialysis center

See Also

References

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