Dr.

Marihot Tambunan, SpPD

Daugirdas, John T.; Blake, Peter G.; Ing, Todd S. Handbook of Dialysis, 4th ed.2007 Floege, J.; Johnson, Richard J.; Feehally J. Comprehensive clinical nephrology, 4th ed. 2010 Nissenson , Allen R.; Fine, Richard N. Handbook of dialysis therapy/edited by. 4th ed.2008

I. The most common complications during hemodialysis are :

A.
B. C.

D.
E. F.

G.
H.

Hypotension (20% - 30% of dialysis) Cramps (5% - 20%) Nausea and vomiting (5% - 15%) Headache (5%) Chest pain (2% - 5%) Back pain (2% - 5%) Itching (5%), and Fever and chills (<1%)

II. Less common (but serious complications) are :

A.

B.
C. D. E. F. G. H.

Disequilibrium syndrome Hypersensitivity reactions Arrhythmia Cardiac tamponade Intracranial bleeding Seizures Hemolysis, and Air embolism

I. A. Hypotension
Blood pressure = Cardiac output x Peripheral resistance

Causes of intradialytic hypotension

1.

Volume related
Hypotension related to excessive or rapid decreases in blood volume Large weight gain (high ultrafiltration rate) Short dialysis (high ultrafiltration rate) Low target weight Nonvolumetric dialysis (inaccurate or erratic ultrafiltration) Low dialysis solution Na (intracellular fluid shift)

Treatment :
Use an ultrafiltration controller.

Avoid large interdialytic weight gain treatment

(IDWG; e.g., to <1 kg per day). Avoid short treatment

KDOQI 2006 guidelines recommend that treatment time not be reduced below 3 hours (for thrice-weekly dialysis) in patients with little or no residual urine output regardless of how high their Kt/V may be.

Increase in treatment time. Four times per week schedule, to avoid a two-day interdialytic interval, is also quite effective.

Treatment
Limit salt intake. Salt restriction is far more

effective in decreasing IDWG than fluid restriction. Use an appropriate dialysis solution sodium level.
The so-called sodium gradient dialysis is widely practiced. It generally involves use of a high dialysis solution sodium early in treatment (145-155 mM) with a progressive fall (linear, step, or logarithmic) to lower levels (135-140 mM) at the end of treatment. The objective is to obtain the benefits of highsodium dialysis solution without its complications.

2. Inadequate vasoconstriction

Hypotension related to lack of vasoconstriction. Reduction in peripheral vascular resistance or cardiac filling in this setting can precipitate hypotension.

 The

causes of inadequate vasoconstriction :

High dialysis solution temperature Autonomic neuropathy Antihypertensive medications Eating during treatment Anemia Acetate buffer

Treatment of inadequate vasoconstriction :

Lower dialysis solution temperature.

Levels of 35.5-36.0C are better initial choices with adjustment made up or down depending on tolerance (chills) and effectiveness (blood pressure).

Avoid intradialytic food ingestion in hypotension-prone patients. The food effect on blood pressure probably lasts at least 2 hours. Patients who are prone to hypotension during dialysis should avoid eating just before or during a dialysis session.

Minimize tissue ischemia during dialysis. Tissue ischemia release adenosine blocks release of norepinephrine and also has intrinsic vasodilator properties severe hypotension. Patients with low hematocrit levels (e.g., <20% 25%) are very susceptible to dialysis hypotension (Sherman et al., 1986). Midodrine, an orally acting I-adrenergic agonist, has been shown to limit intradialytic hypotension in several studies. Stop antihypertensive medication just before HD

3. Cardiac factors
Diastolic dysfunction Arrhythmia (atrial fibrillation) Ischemia

Treatment :
A dialysis solution calcium concentration of

1.75 mM helps maintain intradialytic blood pressure better than a level of 1.25 mM, especially in patients with cardiac disease (van der Sande et al., 1998).

4. Uncommon causes :
Unusual causes of hypotension during dialysis. Rarely, hypotension during dialysis may be a sign of an underlying, serious event

Pericardial tamponade Myocardial infarction Occult hemorrhage Septicemia Dialyzer reaction Hemolysis Air embolism

Detection of hypotension during dialysis : Feeling dizzy, light-headed, nausea. muscle cramps. lack of alertness, darkening of vision

Management :

Management of the acute hypotensive episode is straightforward. Trendelenburg position and a bolus of 0.9% saline (100 mL or more, as necessary) The ultrafiltration rate should be reduced to as near zero as possible. Ultrafiltration can be resumed (slower rate) once vital signs have stabilized. As an alternative to saline, glucose, mannitol, or albumin solutions can be used. Slowing the blood flow rate.

Strategy to help prevent hypotension during dialysis

Use a dialysis machine with an ultrafiltration controller. Counsel patient to limit salt intake, which will result in a lower interdialytic weight gain

(ideally <1 kg per day). Reassess the patient's dry weight. Use a dialysis solution with a time-averaged concentration of sodium of 140-145 mM, as tolerated. Give daily dose of antihypertensive medications after, not before, dialysis. Use bicarbonate-containing dialysis solution. Use a dialysis solution temperature of 35.5C with adjustment downward (or upward) as needed and tolerated. Ensure a predialysis hemoglobin level of 11 g/dL (110 g/L). Do not give food or glucose orally during dialysis to hypotension-prone patients. Consider use of a blood volume monitor. Consider use of -adrenergic agonist (midodrine) prior to dialysis. Consider a 6-week trial of sertraline. Extend the length of dialysis by 30 minutes.

B. Muscle cramps
Etiology of muscle cramps during dialysis is unknown. Predisposing factors are :

hypotension, hypovolemia (dry weight too low),

high ultrafiltration rate (large weight gain), and use of low-sodium dialysis solution vasoconstriction muscle hypoperfusion impairment of muscle relaxation.

The frequency of cramping increases logarithmically with the weight loss

Management muscle cramps :

0.9% saline, hypertonic solutions (saline, glucose, mannitol) may be more effective in dilating muscle-bed blood vessels. Nifedipine (10 mg) has also been found to reverse cramping.

Prevention muscle cramps :

Prevention of hypotensive episodes . Avoiding low predialysis levels of sodium, magnesium, calcium, and potassium Quinine sulfate before dialysis is quite effective in preventing intradialytic cramps. Carnitine, oxazepam, and prazosin may reduce intradialytic muscle cramps (Ahmad et al., 1990). Stretching exercises.

C. Nausea and vomiting

Etiology is multifactorial and are probably related to hypotension. Can be an early manifestation of the socalled disequilibrium syndrome. Dialyzer reactions can cause nausea and vomiting. High sodium and calcium in dialysis solution may cause nausea and vomiting.

Management nausea and vomiting

The first step is to treat any associated hypotension. Antiemetics can be administered

Prevention nausea and vomiting :

Avoid hypotension during dialysis is of prime importance. A single predialysis dose of 5-10 mg metoclopramide is sufficient.

D. Headache
Etiology is largely unknown. It may be a subtle manifestation of the disequilibrium syndrome. Manifestation of caffeine withdrawal in patients who are coffee drinkers as the blood caffeine concentration is acutely reduced during the dialysis treatment. Atypical or particularly severe headache, a neurologic cause (particularly a bleeding event precipitated by anticoagulation) should be considered.

Management :
Acetaminophen can be given during dialysis.

Prevention :
Decreasing dialysis solution sodium A cup of strong coffee may help prevent (or

treat) caffeine withdrawal symptoms.

E. Chest pain and back pain

The cause is unknown. The occurrence of angina during dialysis is common Other potential causes of chest pain are : hemolysis, air embolism, pericarditis.

There is no specific management or prevention strategy, though switching to a different variety of dialyzer membrane may be of benefit.

F. Itching

A common problem in dialysis patients Sometimes precipitated or exacerbated by dialysis. May be a manifestation of low-grade hypersensitivity to dialyzer or blood circuit components. Viral (or drug-induced) hepatitis should not be overlooked as a potential cause of such itching. Pruritus often find in elevated serum Ca-P product and/or substantially elevated PTH level

Management Itching :

Standard symptomatic treatment using antihistamines General moisturizing and lubrication of the skin using emollients Ultraviolet light therapy, especially UVB light, may be of help (Blachley et al., 1985). Reductions in serum Ca-P, and PTH levels are indicated. Uremic pruritus is helped by an increased dose of dialysis Use of a high flux or polymethylmethacrylate membrane, Capsaicin cream, oral activated charcoal, tacrolimus ointment, evening primrose oil, or erythropoietin (all reported to be of benefit).

G. Fever and chills

The dialysis patient with bacteremia generally presents with chills and fever. Redness, tenderness, or exudate at the access site the source of the infection. Low-grade fever during HD pyrogenic reaction in the dialysis solution. Patients with pyrogen-related fever are afebrile prior to dialysis but become febrile during HD; fever resolves spontaneously after cessation of HD Use of high-flux dialysis and dialyzer reuse are associated with an increased incidence of pyrogenic reactions Occasionally bacteremia may result from contamination of HD machines. These are generally Gram -tive and occasionally fungal infections

II. A. Disequilibrium syndrome (DS) is a systemic and neurologic symptoms often associated with

characteristic EEG findings that can occur either during or following dialysis manifestations : nausea, vomiting, restlessness, and headache. More serious manifestations include seizures, obtundation, and coma The cause of the DS is controversial. May be related to an acute increase in brain water content. Plasma solute level is rapidly lowered during dialysis plasma hypotonic the water shifts from the plasma into brain tissue. The others cause is acute changes in the pH of the cerebrospinal fluid during dialysis

The DS was a much larger problem two or more decades ago, when acutely uremic patients with very high serum urea nitrogen values were commonly subjected to prolonged dialysis

Management
a.

Mild disequilibrium Symptoms : nausea, vomiting, restlessness, and headache. Treatment is symptomatic. the blood flow rate should be reduced . Hypertonic sodium chloride or glucose solutions can be given Severe disequilibrium Symptoms : seizures, obtundation, or coma, Treatment : dialysis should be stopped. Intravenous mannitol may be of benefit. If coma is due to disequilibrium, then the patient should improve within 24 hours.

b.

Prevention
a.

Acute dialysis setting Planning dialysis for an acutely uremic patient, should not prescribe an overly aggressive treatment session . Target reduction in the plasma urea nitrogen level --> be limited to about 40%. Use of a low-sodium dialysis solution can exacerbate cerebral edema A hypernatremic patient initially dialyze with a dialysis solution sodium value close to the plasma level and then to correct the hypernatremia slowly postdialysis by administering 5% dextrose. Chronic dialysis setting The incidence of DS can be minimized by use of a dialysis solution with a sodium concentration of at least 140 mM and a glucose concentration of at least 200 mg/dL (11 mmol/L). Using a high dialysis solution sodium concentration (145-150 mM) has been advocated in this setting. There is evidence that use of this approach reduces the incidence of DS-type intradialytic symptoms.

b.

B. Dialyzer reactions

Type A (anaphylactic type)

Manifestations : Dyspnea, a sense of impending doom, feeling of warmth at the fistula site or throughout the body. Cardiac arrest and even death may supervene. Milder cases : itching, urticaria, cough, sneezing, coryza, or watery eyes. Gastrointestinal : abdominal cramping, diarrhea.

Patients with a history of atopy and/or with eosinophilia are prone to develop these reactions. Symptoms usually begin during the first few min. of dialysis, but onset may occasionally be delayed for up to 30 min. or more.

Etiology Ethylene oxide, was used to sterilize almost all hollow-fiber dialyzers in the late 1980s AN69 membrane-associated reactions Contaminated dialysis solution with high levels of bacteria and endotoxin Reuse dialyser, cause by inadequate dialyzer disinfection during the reuse procedure, but in many cases the cause is unknown Heparin, can cause allergic reactions (urticaria, nasal congestion, wheezing, and even anaphylaxis)

Management.
Identifying the actual cause of a dialyzer reaction is frequently not possible. It is safest to stop dialysis immediately, clamp the blood lines, and discard the dialyzer and blood lines. Immediate cardiorespiratory support may be required. Treatment with intravenous antihistamines, steroids, and epinephrine can be given.

Prevention
Proper rinsing of dialyzers prior to use is

important to eliminate residual ethylene oxide and other putative allergens. Patient on a reuse program and even new dialyzers placing to the reuse procedure prior to first Heparin-free dialysis or citrate anticoagulation should be considered

Nonspecific type B dialyzer reactions

Type B reactions are much less severe than

type A reactions Symptoms, are chest pain, sometimes accompanied by back pain Symptom onset is usually 20-40 min. after starting dialysis The cause is unknown. Complement activation has been suggested play a role Symptomps may occur less frequently with reused dialyzers than with new dialyzers

Management

Management is supportive. Nasal oxygen should be given. Myocardial ischemia should be considered, and angina pectoris, if suspected, can be treated. Dialysis can usually be continued, as symptoms invariably abate after the first hour.

Prevention

Initiating dialyzer reuse or trying a different dialyzer membrane may be of value.

III. Visual and hearing loss

The osmolar gradients that develop in dialysis between the blood and the intraocular fluid and vestibular system may alter sensory function. Transient blindness in patients with glaucoma and hearing loss due to endolymphatic hydrops have been reported to occur during dialysis (Evans et al., 2005). Complications of heparin administration (inner ear, vitreous or retinal hemorrhage) may result in similar clinical findings. Intradialytic hypotension or unrelated vascular events can also alter visual and auditory function.