Dialysis complications: Difference between revisions
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==Differential Diagnosis==
==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 DDX}}
{{Dialysis complications DDX}}


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


===[[Infection of AV fistula]]===
==Peritoneal Dialysis Complications==
*Pts often p/w signs of systemic [[sepsis]] ([[fever]], [[hypotension]], leukocytosis)
*[[Peritoneal dialysis-associated peritonitis]]: cloudy effluent, abdominal pain, fever
**Classic signs of pain, erythema, swelling, d/c from infected access are often missing
**Send peritoneal fluid for cell count, Gram stain, culture
*Dialysis catheter–related bacteremia is common and potentially life-threatening
**Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
**Give [[vancomycin]] 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
*Catheter malposition, obstruction, leakage
**Do not remove dialysis patient's access
*Exit site/tunnel infection: erythema, drainage at catheter site
*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 of AV fistula]]===
==Altered Mental Status in Dialysis Patients==
*Potentially life-threatening
*[[Hypotension]]
*Can result from aneurysms, anastomosis rupture, or over-anticoagulation
*[[Hypoglycemia]]
*Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
*Types
*[[Subdural hematoma]] (from anticoagulation during dialysis)
**Aneursym (true)
*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
***Most are asymptomatic; rarely rupture
*[[Stroke]]
**Pseudoaneurysm
*[[Uremia]] (inadequate dialysis)
***Results from subcutaneous extravasation of blood from puncture sites
*Medication accumulation (renally cleared drugs)
***Bleeding from puncture site is usually controlled by digital pressure or subq suture
*Sepsis
***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 from AV fistula]]===
{{ESRD Associated Skin Conditions}}
*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
**Tx = surgical banding of the access


==Peritoneal Dialysis Complications==
==Evaluation==
===Peritonitis===
*[[ECG]] (hyperkalemia changes — peaked T waves, widened QRS)
====Background====
*[[BMP]]: K, Ca, BUN, Cr, glucose
*Most common complication
*[[CBC]], blood cultures if febrile
*Presentation no different from other causes of peritonitis
*[[CXR]]: pulmonary edema, line placement
====Diagnosis====
*Access exam: check thrill/bruit
*Send dialysate fluid for cell count, Gram stain, cx (if available)
 
**Cell count >100 w/ >50% neutrophils most c/w infection
==Disposition==
====Treatment====
*Low threshold for admission — these are high-risk patients
*Can add [[antibiotic] to the dialysate if possible (parenteral abx not required)
*Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
**1st gen [[cephalosporin]] or [[vancomycin]] (if pen allergic)
*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]]


==Source==
==References==
Tintinalli
<references/>


[[Category:Nephro]]
[[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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