Dialysis complications

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

• Dialysis-associated hypotension
• Dialysis disequilibrium syndrome
• Air embolism
• Missed dialysis (pulmonary edema)

AV Fistula Complications

• Clotting of AV fistula
• Infection of AV fistula
• Hemorrhage of AV fistula
• Vascular insufficiency from AV fistula
• AV fistula aneurysm/pseudoaneurysm
• High-output heart failure from 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

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

• Hypotension
• Hypoglycemia
• Hypercalcemia / Hyperkalemia / Hyponatremia
• Subdural hematoma (from anticoagulation during dialysis)
• Dysequilibrium syndrome - diagnosis of exclusion made after admission
• Stroke
• Uremia (inadequate dialysis)
• Medication accumulation (renally cleared drugs)
• Sepsis

ESRD Associated Skin Conditions

• Calciphylaxis
• Nephrogenic Systemic Fibrosis (gadolinium MRI)

Cardiovascular

• Cardiac tamponade
• Pericarditis

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