Author:
Erika PhindileChowa
Brooks L.Moore
Description
Dialysis complications may be:
- Vascular access related (infection, bleeding)
- Nonvascular access related (hypotension, hyperkalemia)
- Peritoneal dialysis (PD) related
Etiology
- Vascular access related:
- Infections:
- Infections (largely access related) are a major cause of death in dialysis patients
- Often caused by Staphylococcus aureus
- Can present as a localized infection or systemic
- Hemodialysis catheters have a 2-3-fold increased risk of infection than the AV fistula or graft
- Infectious complications include endocarditis, osteomyelitis, spinal epidural abscess, septic arthritis, brain abscess, and septic pulmonary emboli
- AV graft/fistula thrombosis or stenosis:
- Thrombosis and stenosis are the most common complications of AV access for hemodialysis
- Must be addressed quickly (within 24 hr) to avoid loss of access site
- Management is mostly surgical; however, interventional treatment also used
- Bleeding:
- Aneurysmal formation and /or bacterial infection weaken the vessel wall, increasing the risk for bleeding
- Bleeding occurs post HD after catheter is disconnected from AV access site
- Nonvascular access related:
- Hypotension:
- Most common nonvascular 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 dialysis related:
- Peritonitis:
- Owing to contamination of peritoneal dialysate or tubing during exchange:
- This can be from translocation of bacteria from bowel. Perforated viscus can present similarly
- S. aureus or Staphylococcus epidermidis (70%)
- A majority of patients received PD will develop at least one episode of peritonitis in their lifetime
- Fibrinous blockage of catheter which results from infection or inflammation
Signs and Symptoms
- Vascular access related:
- Bleeding from puncture sites
- Loss of bruit or thrill over fistula or 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
- Tachycardia
- Palpitations
- Syncope
- Chest pain:
- Hemorrhage:
- 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:
- Look for signs of infection, feel for pain and lack of palpable thrill in AV access
- 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
- ECG: Look for signs of electrolyte balance or conduction disturbances
- Infection:
- Blood cx, peritoneal fluid cx, and wound cx
- 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
- ECG, cardiac enzymes (if appropriate, based on history)
- Neurologic dysfunction: CT of brain for intracranial hemorrhage
Diagnostic 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 cathetergram for blockages
- CT scan for pulmonary embolism or brain:
- IV contrast administration can be given in renal insufficiency:
- Communicate contrast load to renal team; however, urgent dialysis is not indicated
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
Prehospital
ALERT |
- Do not perform IV access and BP measurement in extremity with functioning AV graft or fistula
- Run IV fluids slowly and keep to min, if possible
- Administer furosemide in pulmonary edema (anuric patients: Use high doses ≤200 mg)
|
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
- Noninvasive positive pressure ventilation should be considered
- Arrange for urgent dialysis
- Hyperkalemia:
- Administer IV calcium, bicarbonate, insulin, and glucose when appropriate (see “Hyperkalemia”)
- Monitor cardiac rhythm
- Administration of ion-exchange resin (Kayexalate) is controversial
- Arrange for urgent dialysis
- Neurologic complications:
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:
- After initial stabilization arrange for dialysis
- If dialysis not readily available:
- Diuresis with furosemide after preload and afterload reduction (nitroglycerin, enalapril)
- Keep patient on monitor
- Continue managing electrolyte abnormalities
- Volume overload:
- Attempt diuresis with nitrites and furosemide
- Noninvasive positive pressure ventilation when indicated
- 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 cand idate
- 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/IM followed by 250 mg/2 L bag for 10 d (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 mcg/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 units regular insulin IV (with D50 for hyperkalemia)
- Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV/IM initial dose
- Nitroglycerin: 0.4 mg sublingually; 5-20 mcg/min IV
- Sodium bicarbonate: 1 mEq/kg up to 50-100 mEq IV p.r.n
- Sodium polystyrene sulfonate (Kayexalate): 1 g/kg up to 15-60 g PO or 30-50 g retention enema q6h p.r.n (for hyperkalemia)
- Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV/IM
- Tobramycin: 1.7 mg/kg IV/IM followed by 10 mg/2 L bag for 10 d (peritonitis)
- Vancomycin: 1 g IV/IM followed by 50 mg/2 L bag for 10 d (peritonitis)
Disposition
Admission Criteria
- ICU admission:
- Severe hyperkalemia
- Severe pulmonary edema
- Persistent hypotension
- Uncontrolled seizures
- Acute MI
- Cardiovascular accident
- Pericarditis
- Severe 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
- FeldmanHI, HeldPJ, HutchinsonJT, et al. Hemodialysis vascular access morbidity in the United States . Kidney Int. 1993;43(5):1091-1096.
- KhanIH, CattoGR. Long-term complications of dialysis: Infection . Kidney Int Suppl. 1993;41:S143-S148.
- MillerL, ClarkE, Dipchand C, et al. Hemodialysis Tunneled Catheter-Related Infections . Can J Kidney Health Dis. 2016;3:1-11.
- PadbergFT Jr, CalligaroKD, SidawyAN. Complications of arteriovenous hemodialysis access: Recognition and management . J Vasc Surg. 2008;48:55S-80S.
- ZinkJN, NetzleyR, ErzurumV, et al. Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access . J Vasc Surg. 2013;57:144-148.
See Also (Topic, Algorithm, Electronic Media Element)
The authors gratefully acknowledge Christopher B. Colwell for his contribution to the previous edition of this chapter.