DESCRIPTION

Dialysis complications may be:

• Vascular access related (infection, bleeding)
• Nonvascular access related (hypotension, hyperkalemia)
• Peritoneal (abdominal pain, infection)

ETIOLOGY

• Vascular access related:
  • Infections:
    • Infections (largely access related or peritonitis) are a major cause of death in dialysis patients.
    • Often caused by Staphylococcus aureus
    • Can present with signs of localized infection or systemic sepsis
    • Can also present with minimal findings
  • Thrombosis or stenosis:
    • Often presents with loss of bruit or thrill over access site
    • Must be addressed quickly (within 24 hr) to avoid loss of access site
  • Bleeding:
    • Can be life-threatening
    • Aneurysm
• Nonvascular access related:
  • Hypotension:
    • Most common complication of hemodialysis
    • After dialysis: Often owing to acute decrease in circulating blood volume
    • During dialysis: Hypovolemia (more commonly) or onset of cardiac tamponade owing to compensated effusion suddenly becoming symptomatic after correction of volume overload
    • MI, sepsis, dysrhythmias, hypoxia
    • Hemorrhage secondary to anticoagulation, platelet dysfunction of renal failure
  • Shortness of breath:
    • Volume overload
    • Development of dyspnea during dialysis owing to tamponade, pericardial effusion, hemorrhage, anaphylaxis, pulmonary embolism, air embolism
  • Chest pain:
    • Ischemic:
      • Dialysis patients are often at high risk for having atherosclerotic disease
      • Dialysis is an acute physiologic stressor with transient hypotension and hypoxemia that increases myocardial oxygen demand.
    • Pleuritic:
      • Pericarditis, pulmonary embolism
  • Neurologic dysfunction: Disequilibrium syndrome:
    • Rapid decrease in serum osmolality during dialysis leaves brain in comparatively hyperosmolar state.
• Peritoneal:
  • Peritonitis:
    • Owing to contamination of peritoneal dialysate or tubing during exchange
    • S. aureus or Staphylococcus epidermidis (70%)
  • Perforated viscus with abdominal pain that can be severe, fever, brown or fecal material in effluent, or localized tenderness
  • Fibrinous blockage of catheter resulting from infection or inflammation

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Vascular access related:
  • Bleeding from puncture sites
  • Loss of bruit in graft
  • Local infection, cellulitis, fever
  • Decreased sensation and strength distal to access
  • New or increasing size mass adjacent to access site
• Nonvascular access related:
  • Hypotension before, during, or after procedure
  • Palpitations
  • Syncope
  • Chest pain:
    • Ischemic
    • Pleuritic
  • Hemorrhage:
    • GI
    • Pleural
    • Retroperitoneal
  • Shortness of breath:
  • Neurologic symptoms (disequilibrium syndrome):
    • Headache
    • Malaise
    • Seizures
    • Coma
• Peritoneal:
  • Abdominal pain
  • Cloudy dialysis effluent
  • Nausea and vomiting
  • Exudates or inflammation at insertion site of Tenckhoff catheter

ESSENTIAL WORKUP

• Careful physical exam:
  • Complete set of vital signs including auscultated BP, pulse, respiratory rate, accurate temperature, and pulse oximetry
  • Careful physical exam for occult infectious sources (odontogenic, perirectal abscess)
  • Auscultation of lungs for evidence of infection (rhonchi) or volume overload (rales)
  • Search for other evidence of volume overload (edema)
  • Careful cardiac exam including listening for murmurs or rubs
• EKG: Look for signs of electrolyte balance or conduction disturbances.
• Infection:
  • Blood and wound cultures
  • Cell count, Gram stain, culture of peritoneal fluid
• Bleeding:
  • CBC to evaluate anemia and platelet count
  • Coagulation studies
• Chest pain or shortness of breath:
  • Chest radiograph
  • ABG
  • EKG, cardiac enzymes (if appropriate, based on history)
• Neurologic dysfunction: CT of brain for intracranial hemorrhage

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Glucose, electrolytes, BUN, and creatinine
• CBC

Imaging

• ECG for suspected:
  • Hyperkalemia
  • Pericarditis
  • Effusion
  • Tamponade
• US of access for possible clotted graft or fistula
  • ECHO to assess for pericardial effusion/tamponade
• Peritoneal cathergram for blockages
• CT scan for pulmonary embolism:
  • Dialysis patients are at risk for both bleeding and clotting problems.
  • Problematic in renal insufficiency owing to contrast dye load:
    • Can be done in renal failure, but contrast is then a fluid bolus and may need to be dialyzed off
    • Communicate contrast load to renal team, as dialysis may need to occur for longer-than-normal duration.

DIFFERENTIAL DIAGNOSIS

• Hypotension:
  • Sepsis
  • Cardiogenic shock, acute MI, tamponade, primary dysrhythmias
  • Electrolyte abnormalities leading to dysrhythmias (hyperkalemia and hypokalemia)
  • Embolism: Air or pulmonary
  • Hypovolemia
  • Vascular instability: Autonomic neuropathy, drug related, dialysate related
• Neurologic complications:
  • Cerebrovascular accident
  • Disequilibrium syndrome
  • Hyperglycemia or hypoglycemia
  • Hypernatremia or hyponatremia
  • Hypoxemia
  • Intracranial bleed
  • Meningitis or abscess
  • Uremia
• Peritoneal complications:
  • Peritonitis
  • Hernia incarceration
  • Perforated viscus
  • Acute abdominal process: Appendicitis, cholecystitis

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

ALERT

INITIAL STABILIZATION/THERAPY

• Check airway, breathing, and circulation.
• Vascular access related:
  • Bleeding:
    • Firm pressure to site(s)
    • Do not totally occlude access; may cause clotting.
    • Will likely need pressure applied for at least 5–10 min to stop even minor bleeding
    • Document presence or absence of thrill after pressure was applied.
    • Apply Gelfoam.
• Nonvascular access related:
  • Hypotension:
    • Search for underlying cause.
    • Vasopressors, fluids
  • Shortness of breath:
    • Preload and afterload reduction with nitrites and ACE inhibitors.
    • Attempt diuresis if fluid overload is suspected cause.
    • Arrange for dialysis.
  • Hyperkalemia:
    • Administer IV calcium, bicarbonate, insulin, and glucose when appropriate (see "Hyperkalemia").
    • Monitor cardiac rhythm.
    • Administer ion-exchange resin (Kayexalate).
    • Arrange for dialysis.
  • Neurologic complications:
    • Administer naloxone, thiamine, dextrose (or Accu-Chek) for altered mental status.
    • Control seizures with benzodiazepines.

ED TREATMENT/PROCEDURES

• Vascular access related:
  • Infection:
    • Initiate antistaphylococcal IV antibiotics.
  • Clotted access:
    • Analgesia
    • Warm compresses
    • Vascular surgery consult
  • Hemorrhage:
    • Control bleeding.
    • Correct coagulopathies.
    • Administer IV fluids and blood products.
• Nonvascular access related:
  • Electrolyte imbalances:
    • Treat hypercalcemia or hypermagnesemia with saline infusion if tolerated (dilution).
    • Diuresis with furosemide after preload and afterload reduction (nitroglycerin, enalapril)
    • Arrange for dialysis.
  • Volume overload:
    • Attempt diuresis with nitrites and furosemide.
    • Arrange for dialysis.
  • Pericardial effusion or tamponade:
    • Emergent pericardiocentesis may be necessary in unstable patient.
    • Arrange for dialysis.
  • Acute MI:
    • Thrombolytics or angioplasty if patient is appropriate candidate
    • Nitrates to decrease myocardial workload
  • Disequilibrium syndrome:
    • Rule out other causes of altered mental status.
    • Generally resolves over time
• Peritoneal:
  • Peritonitis: IV or intraperitoneal antibiotics
  • Culture catheter or tunnel infection, visible exudates:
    • Oral antibiotics (antistaphylococcal)
    • If recurrent or tunnel, may need to be unroofed
    • Meticulous site care
  • Perforated viscous:
    • IV antibiotics
    • Surgical consultation

MEDICATION

• Calcium gluconate: 1 g slowly IV (cardioprotective in hyperkalemia with widened QRS complex)
• Cefazolin: 1 g IV or IM followed by 250 mg/2 L bag for 10 days (peritonitis)
• Captopril: 25 mg sublingually
• Dextrose D₅₀W: 1 amp: 50 mL or 25 g (peds: dextrose D₂₅W: 2–4 mL/kg)IV
• Dopamine: 2–20 µg/kg/min IV
• Enalapril: 1.25 mg IV
• Furosemide: 20–100 mg IV (may require doses of ≥30 mg to effect diuresis in chronic renal failure)
• Insulin: 5–10 U regular insulin IV (with D₅₀ for hyperkalemia)
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
• Nitroglycerin: 0.4 mg sublingually; 5–20 µg/min IV
• Sodium bicarbonate: 1 mEq/kg up to 50–100 mEq IV PRN
• Sodium polystyrene sulfonate (Kayexalate): 1 g/kg up to 15–60 g PO or 30–50 g retention enema q6h PRN (for hyperkalemia)
• Thiamine (vitamin B₁): 100 mg (peds: 50 mg) IV or IM
• Tobramycin: 1.7 mg/kg IV or IM followed by 10 mg/2 L bag for 10 days (peritonitis)
• Vancomycin: 1 g IV or IM followed by 50 mg/2 L bag for 10 days (peritonitis)

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• ICU admission:
  • Severe hyperkalemia
  • Pulmonary edema
  • Volume overload
  • Persistent hypotension
  • Uncontrolled seizures
  • Acute MI
  • Cardiovascular accident
  • Pericarditis
  • Sepsis
  • Peritonitis with toxic or systemic symptoms
• Regular admission:
  • Fever
  • Vomiting
  • Peritonitis without toxic or systemic symptoms
  • Non–life-threatening electrolyte disturbances
  • Inability to provide self-care for continuous ambulatory peritoneal dialysis with antibiotics

Discharge Criteria

• Mild infections of access site
• Same-day surgery for some thrombectomy procedures
• Hemostasis at puncture sites

FOLLOW-UP RECOMMENDATIONS

Most patients on dialysis are followed closely by their nephrologists.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Consider cardiac tamponade in dialysis patients, even when they don't exhibit classic symptoms.
• Always consider hyperkalemia in dialysis patients.
• Infections can have very subtle presentations in dialysis patients and are a common cause of morbidity and mortality
• Early vascular surgery consultation is important for patients with clotted or ruptured access sites

ICD9

• 996.1 Mechanical complication of other vascular device, implant, and graft
• 996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft
• 999.9 Other and unspecified complications of medical care, not elsewhere classified

ICD10

• T80.29XA Infct fol oth infusion, transfuse and theraputc inject, init
• T80.90XA Unsp comp following infusion and therapeutic injection, init
• T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter

[Outline]

• ICD9
• ICD10

• Feldman HI, Held PJ, Hutchinson JT, et al. Hemodialysis vascular access morbidity in the United States. Kidney Int. 1993;43(5):1091–1096.
• Khan IH, Catto GR. Long-term complications of dialysis: Infection. Kidney Int Suppl. 1993;41:S143–S148.
• Zink JN, Netzley R, Erzurum V, et al. Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access. J Vasc Surg. 2013;57:144–148.
• Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48:55S–80S.

See Also (Topic, Algorithm, Electronic Media Element)

• Renal Failure
• Hyperkalemia

Christopher B. Colwell