Basics
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
Diagnosis
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:
- 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:
- 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
Treatment
Pre-Hospital
- 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 ā¤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.
- 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 Ī¼g/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 Ī¼g/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)
Follow-Up
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
Followup Recommendations
Most patients on dialysis are followed closely by their nephrologists.
Pearls and Pitfalls
- Consider cardiac tamponade in dialysis patients, even when they dont 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
Additional Reading
- 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
Codes
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
- 996.68 Infection and inflammatory reaction due to peritoneal dialysis catheter
- 996.56 Mechanical complication due to peritoneal dialysis catheter
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
- T82.7XXA Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init
- T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial encounter
- T82.828A Fibrosis of vascular prosthetic devices, implants and grafts, initial encounter
- T82.868A Thrombosis of vascular prosth dev/grft, init
SNOMED
- 19765000 Complication of dialysis (disorder)
- 85223007 Complication of hemodialysis (disorder)
- 33461007 Complication of peritoneal dialysis (disorder)
- 430332005 Infection of arteriovenous graft for hemodialysis (disorder)
- 17778006 Mechanical complication of dialysis catheter (disorder)
- 430958003 Infection of peritoneal dialysis catheter (disorder)
- 473034005 Complication associated with dialysis catheter (disorder)