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 (20%-30% of tx)
*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===
*Diagnosis of exclusion (r/o SDH, CVA)
*'''[[Hyperkalemia]]''': most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
*Clinical syndrome occurring at end of dialysis
*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)
*Characterized by N/V, HTN
*Metabolic acidosis
**Can progress to seizure, coma, death)
*Occurs most commonly during initial dialysis or during hypercatabolic states
*Treat w/ mannitol


==Air Embolism==
==Peritoneal Dialysis Complications==
*Acute dyspnea, chest tightness, LOC, cardiac arrest
*[[Peritoneal dialysis-associated peritonitis]]: cloudy effluent, abdominal pain, fever
*Treat w/ 100% NRB
**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


==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
***Results 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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