Dialysis complications: Difference between revisions
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<h2>Hypotension</h2>
==Background==
<h3>Background</h3>
*Dialysis patients are high-acuity ED patients with unique complications
<ul><li>Most frequent complication of hemodialysis (20%-30% of tx)
*Common presentations: access problems, hypotension, electrolyte emergencies, infections
</li><li>Timing of intradialytic hypotension is helpful in formulating DDX:
*Always check when last dialysis session was and if any were missed
<ul><li>Hypotension early in session usually due to preexisting hypovolemia
 
</li><li>Hypotension during the session is often due to blood loss (from tubing or filter leak)
==Hemodialysis Complications==
</li><li>Hypotension near the end usually result of excessive ultrafiltration
{{Dialysis complications DDX}}
<ul><li>Underestimation of pt's ideal blood volume (dry weight)
 
</li><li>Also consider pericardial or cardiac disease
===Access Complications===
</li></ul>
{{AV shunt complications DDX}}
</li></ul>
*Thrombosed fistula/graft: absent thrill/bruit → vascular surgery referral within 24-48h
</li></ul>
*Hemorrhage from access site: direct pressure x 10-15 min; avoid tourniquet proximal to access
<h3>Clinical Features</h3>
*Infection: erythema, warmth, purulent drainage → blood cultures + empiric [[vancomycin]]; avoid using infected access
<ul><li>N/V
*Steal syndrome: hand ischemia distal to fistula (pain, pallor, cool fingers) → vascular surgery
</li><li>Anxiety
 
</li><li>Dizziness
===During/Post-Dialysis===
</li><li>Orthostatic hypotension
*Hypotension: most common acute complication; give NS bolus (avoid excessive fluid in volume-overloaded patient)
</li><li>Syncope
*[[Dysequilibrium syndrome]]: headache, N/V, AMS, seizures during/after dialysis (especially first sessions) — diagnosis of exclusion after ruling out other AMS causes
</li></ul>
*Air embolism: rare but catastrophic; place in left lateral decubitus/Trendelenburg
<h3>Diagnosis</h3>
*Muscle cramps: NS bolus, reduce ultrafiltration rate
<ol><li>Assess:
 
<ol><li>Volume status (US)
===Missed Dialysis===
</li><li>Cardiac function
*'''[[Hyperkalemia]]''': most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
</li><li>Pericardial disease
*Volume overload / [[pulmonary edema]]: BiPAP, [[nitroglycerin]], [[furosemide]] (limited efficacy in anuric patients), emergent dialysis
</li><li>Infection
*[[Uremic pericarditis]]: friction rub, emergent dialysis; avoid anticoagulation (hemorrhagic risk)
</li><li>GI bleeding
*Metabolic acidosis
</li></ol>
 
</li></ol>
==Peritoneal Dialysis Complications==
<h3>DDX</h3>
*[[Peritoneal dialysis-associated peritonitis]]: cloudy effluent, abdominal pain, fever
<ol><li>Excessive ultrafiltration
**Send peritoneal fluid for cell count, Gram stain, culture
</li><li>Predialytic volume loss
**Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
<ol><li>GI losses
*Catheter malposition, obstruction, leakage
</li><li>Decreased oral intake
*Exit site/tunnel infection: erythema, drainage at catheter site
</li></ol>
 
</li><li>Intradialytic volume loss
==Altered Mental Status in Dialysis Patients==
<ol><li>Tube and hemodialyzer blood losses
*[[Hypotension]]
</li></ol>
*[[Hypoglycemia]]
</li><li>Postdialytic volume loss
*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
<ol><li>Vascular access blood loss
*[[Subdural hematoma]] (from anticoagulation during dialysis)
</li></ol>
*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
</li><li>Medication effects
*[[Stroke]]
<ol><li>Antihypertensives
*[[Uremia]] (inadequate dialysis)
</li><li>Opiates
*Medication accumulation (renally cleared drugs)
</li></ol>
*Sepsis
</li><li>Decreased vascular tone (sepsis)
 
</li><li>Cardiac dysfunction
{{ESRD Associated Skin Conditions}}
<ol><li>LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
 
</li></ol>
==Evaluation==
</li><li>Pericardial disease
*[[ECG]] (hyperkalemia changes — peaked T waves, widened QRS)
<ol><li>Effusion
*[[BMP]]: K, Ca, BUN, Cr, glucose
</li><li>Tamponade
*[[CBC]], blood cultures if febrile
</li></ol>
*[[CXR]]: pulmonary edema, line placement
</li></ol>
*Access exam: check thrill/bruit
<h2>Dialysis Disequilibrium Syndrome</h2>
 
<ul><li>Diagnosis of exclusion (r/o SDH, CVA)
==Disposition==
</li><li>Clinical syndrome occurring at end of dialysis
*Low threshold for admission — these are high-risk patients
<ul><li>Large solute clearances -&gt; cerebral edema
*Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
</li></ul>
*Arrange emergent dialysis for: severe hyperkalemia, pulmonary edema, uremic pericarditis
</li><li>Characterized by N/V, HTN
*Discharge only for minor issues with ensured follow-up at dialysis center
<ul><li>Can progress to seizure, coma, death)
 
</li></ul>
==See Also==
</li><li>Occurs most commonly during initial dialysis or during hypercatabolic states
*[[Hyperkalemia]]
</li><li>Treat w/ mannitol
*[[Peritoneal dialysis-associated peritonitis]]
</li></ul>
*[[Chronic kidney disease]]
<h2>Air Embolism</h2>
 
<ul><li>Acute dyspnea, chest tightness, LOC, cardiac arrest
==References==
</li><li>Treat w/ 100% NRB
<references/>
</li></ul>
 
<h2>Vascular Access Complications</h2>
[[Category:Renal]]
<h3>Thrombosis and Stenosis</h3>
[[Category:Vascular]]
<ul><li>Most common causes of inadequate dialysis flow
<ul><li>Loss of bruit and thrill over access
</li></ul>
</li><li>Stenosis and even thrombosis are not emergencies
<ul><li>Can be treated w/in 24hr by angiographic clot removal or angioplasty
</li><li>Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg ***This therapy should be discussed with the vascular surgeon first
</li></ul>
</li></ul>
<h3>Vascular Access Infection</h3>
<ul><li>Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
<ul><li>Classic signs of pain, erythema, swelling, d/c from infected access are often missing
</li></ul>
</li><li>Dialysis catheter–related bacteremia is common and potentially life-threatening
<ul><li>Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
</li><li>Do not remove dialysis patient's access
</li></ul>
</li><li>Draw peripheral and catheter blood cultures simultaneously
<ul><li>4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
<ul><li>Even so catheter is only removed if fever persists for 2-3d after abx are started
</li></ul>
</li></ul>
</li></ul>
<h3>Hemorrhage</h3>
<ul><li>Potentially life-threatening
</li><li>Can result from aneurysms, anastomosis rupture, or over-anticoagulation
</li><li>Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
</li><li>Types
<ul><li>Aneursym (true)
<ul><li>Most are asymptomatic; rarely rupture
</li></ul>
</li><li>Pseudoaneurysm
<ul><li>Results from subcutaneous extravasation of blood from puncture sites
</li><li>Bleeding from puncture site is usually controlled by digital pressure or subq suture
</li><li>Consider vascular surgery consultation for continued bleeding or infection
</li><li>Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
</li></ul>
</li></ul>
</li></ul>
<h3>Vascular insufficiency</h3>
<ul><li>Distal extremity becomes ischemic due shunting of arterial blood to venous side
<ul><li>Exercise pain, nonhealing ulcers, cool, pulseless digits
</li><li>Diagnosed by Doppler US or angiography, repaired surgically
</li></ul>
</li></ul>
<h3>High-output heart failure</h3>
<ul><li>Occurs when &gt;20% of cardiac output is diverted through the access
<ul><li>Branham sign (drop in HR after temporary access occlusion) is diagnostic
</li><li>Doppler US can accurately measure access flow rate and establish the diagnosis **Surgical banding of the access is treatment of choice
</li></ul>
</li></ul>
<h2>Source</h2>
<p>Tintinalli
</p><a _fcknotitle="true" href="Category:Nephro">Nephro</a>

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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