Complications during

Hemodialysis
Dr forghani . MD
 Complications during
Hemodialysis
• INTRADIALYTIC HYPOTENSION
• MUSCLE CRAMPS
• NAUSEA AND VOMITING
• HEADACHE
• CHEST PAIN AND BACK PAIN
• ITCHING
• DISEQUILIBRIUM SYNDROME
• DIALYZER REACTIONS
• HEMOLYSIS
• AIR EMBOLISM
 INTRADIALYTIC HYPOTENSION

Definition and Importance:

SBP < 90 mmHg or decreased 20-30 mmHg during HD
Distressing symptom and poor out come
Common in patient with predialysis low blood pressure

MECHANISM
•IDH related to blood volume changes
•Hypotension related to lack of vasoconstriction
•Hypotension related to cardiac factors
INTRADIALYTIC HYPOTENSION

 IDH related to blood volume changes

Can be limited IDH with prevention of large blood volume change

1. Avoid large interdialytic weight gains (fluid intake limitation)

2. Increasing weekly treatment time and frequency
3. Maintaining and increasing urinary volume
4. Choose target weight carefully
5. Use an appropriate dialysis solution sodium level
Low Na solution induced IDH ( decreased blood volume)
VS high Na solution that induced HTN , IDWG and Thirst
starting with Na 145-155 then decreased to 135-140
INTRADIALYTIC HYPOTENSION

 Hypotension related to lack of vasoconstriction

Decreased total peripheral resistance (TPR)
(arterial pressure shift to Vein)

1. Lower dialysis solution temperature (35.5-36)

2. Avoid intradialytic food ingestion (splanchnic vasodilation)
3. Minimize tissue ischemia (due to anemia HCT<25 and hypotension increase
Adenosine) during dialysis transfusion can be useful
4. Midodrine ( alpha agonist 10 mg 1h pre HD)
5. Sertraline (4-6 week administration improve autonomic function)
6. Antihypertensive medication (after HD , decrease or D/C )
7. Dialysis fluid potassium level (higher K solution)
8. Fludrocortisone (in adrenal insufficiency)
9. Vasopressin (constricts splanchnic vessels)
INTRADIALYTIC HYPOTENSION

 Hypotension related to cardiac factors

• Diastolic dysfunction is common (stiffness and hypertrophy decrease
filling pressure and cardiac out put) improve with Verapamil
• Heart rate and contractility (compensatory mechanism dysfunction)
• Dialysis solution calcium (dialysate Ca 1.7 mm VS 1.25)

 Detection of hypotension (symptom and sign, regular

BP measurement Q1h or 30 min)
 Management of IDH ( position, saline 0.9, hypertonic
saline increase vasopressin, albumin, glucose, mannitol infusion,
decrease or off UF, decrease BFR when we use acetate)
Strategy to Help Prevent Hypotension During Dialysis
 MUSCLE CRAMPS
 Etiology: high prevalence in 1th month of HD starting
(hypotension, hypovolemia, high UF, low Na dialysate) induced
vasoconstriction followed by hypo perfusion, abnormal muscle
relaxation occur. Other cause hypocalcaemia, hypomagnesaemia
hypokalemia, low cardiac index, low K and Ca dialysate

 Management
(saline, glucose , mannitol, nifedipine ,muscle stretching)

 Prevention • Stretching exercises

• Dialysate sodium
• Dialysate magnesium
• Biotin
• Carnitine, oxazepam, and vitamin E
• Quinine
 NAUSEA AND VOMITING

• Etiology and incidence (10% during HD)

Multifactorial,(often during hypotension episode, disequilibrium
syndrome, dialyzer reaction, gastroparesis)

• Management
(hypotension management, antiemetic metoclopramide)

• Prevention
(hypotension avoidance)
  HEADACHE
• Etiology (70% during HD)
Disequilibrium syndrome, caffeine withdrawal, HD predispose migraine
head ache
• Management ( acetaminophen during HD)
• Prevention (Coffee during HD , change Dialysate Na)
 CHEST PAIN AND BACK PAIN
1-4%, unknown cause; R/O Angina, air emboli, pericarditis, hemolysis;
change dialyzer can be helpful
 ITCHING
Sometimes precipitated or
exacerbated by HD
 ETIOLOGY: low grade
hypersensitivity to dialyzer or
blood circuit , hepatitis, scabies
 TREATMENT:
• moisturizing
• dialysis adequacy
• hyperparathyroidism
• hyperphosphatemia treatment
• antihistamin
• charcoal
• Gabapentin
• Nalfurafine central KOA
DISEQUILIBRIUM SYNDROME
• Definition
(include neurologic and systemic symptoms during or after HD)
Nausea ,vomiting, restlessness, head ache, seizure, coma
• Etiology (brain edema, CSF PH change)
• Management:
• Mild disequilibrium symptomatic, decrease BFR or solute removal
and avoid PH severe change, HD discontinuation
• Severe disequilibrium HD discontinuation, saline, mannitol

• Prevention:
In acute HD :URR 40% in first HD, Dialysate Na near to plasma Na
In chronic HD: Dialysate Na 140, high Na 145-150 that declines over
the course of HD
DIALYZER REACTIONS
 Type A (anaphylactic type)

Manifestations
mild : pruritus, urticaria, cough, coryza, sneezing, diarrhea, abdominal cramp
Severe: impending doom, dyspnea, feeling warmth at AVF or body, cardiac arrest, death

Ethylene oxide
Etiology Contaminated dialysis solution (bacteria and endotoxin ,
symptomatic In first 2 minutes)
Heparin: (urticaria , nasal congestion, anaphylaxis)

Management: blood line clamp, HD d/c, cardiopulmonary support,

antihistamine, steroid, epinephrine
Prevention: ethylene oxide change to gamma radiation, after R/O
other causes heparin can be D/C, ACEI d/c in AN69 dialyzer use
  Nonspecific type B dialyzer
reactions
• Symptoms: back pain and chest pain 20-40 minute past
HD starting, less severe than type A,
• Etiology unknown, possibly complement activation
• Management O2 , R/O angina, HD can be continued,
symptoms often abate after 1 h.
• Prevention trying a different dialyzer
 Air emboli
• Manifestation is potential catastrophe
Symptoms: in seated position, LOS, seizure, death
In recumbent: dyspnea, cough, arrhythmia, chest tightness

Sign: foam in venous line, churning sound

• Etiology: arterial needle and prepump air entry, inadvertently
opened Catheter
• Management: venous line clamp, pump stop, recumbent
position, O2, resuscitation, ventricular air aspiration
 HEMOLYSIS

• Manifestation: chest pain, dyspnea, back pain, muscle

weakness due to hyperkalemia
• Etiology: obstruction or narrowing in blood line, G6PD,
dialysate overheated, hypotonic, contamination with chloramine (city
water)
• Management: D/C Blood pump, hyperkalemia treatment,
transfusion, observed carefully