dialysis

1. ACUTE COMPLICATIONS OF
HEMODIALYSIS
BY
AMIR EL OKELY
MRCP, MD
Prof OF Nephrology

2. Acute complicationAcute complication
 Hypotension — 25 to 55 %
 Cramps — 5 to 20 %
 Nausea and vomiting — 5 to 15 %
 Chest pain — 2 to 5 %
 Back pain — 2 to 5 %
 Itching — 5 %
 Fever and chills — Less than 1 %

3. Intra-dialytic hypotension
 Definition: A decrease in systolic BP ≥20 mm Hg
or a decrease in MAP ≥ 10 mm Hg associated
with symptoms.
 Complication: cardiac arrhythmias, coronary
and/or cerebral ischemic events
 Long-term side effects: volume overload due to
suboptimal ultrafiltration, LVH, and inter-dialytic
hypertension

4. Risk Factors of Dialysis Hypotension
 Low body mass
 Poor nutritional status and hypoalbuminemia
 Severe anemia
 Advanced age (Age > 65 years old)
 Cardiovascular disease
 Large inter-dialysis weight gain
 Low blood pressure (pre-dialysis systolic BP <100 mm
Hg)

5. Etiology of Dialysis Hypotension (I(
 Excessive rate and degree of
ultrafiltration
 Inappropriate peripheral venodilation
 Autonomic dysfunction
 Inadequate vasoconstrictor secretion

6. Etiology of Dialysis Hypotensoin (II(
 Acetate dialysate
 Low calcium dialysate
 Eat shortly before dialysis
 Antihypertensive medications
 LV dysfunction

7. Prevention and Management of Dialysis
Hypotension (I(
 Limiting sodium intake
 Minimize inter-dialytic weight gain
 Blood sugar control
 Slow ultrafiltration
 Sodium modeling
 Raise dialysate calcium
 Lower dialysate temperature

8. Prevention and Management of Dialysis
Hypotension (II(
 Switch to CAPD
 Hyperoncotic albumin
 Nasal oxygen
 Mannitol infusion

9. Prevention and Management of Dialysis
Hypotension (III(
 L-Carnitine therapy
 Sertraline
 Midodrine
 Blood transfusion or EPO therapy
 Volume expansion
 Vasoconstrictor

10. Muscle CrampsMuscle Cramps
 A cramp is a prolonged involuntary muscle
contraction
 common complication of hemodialysis
treatments and mostly involves the muscle of
the lower extremities resulting in early
termination of a hemodialysis session.
 Usually occur near the end of hemodialysis
treatments.
 Low PTH Values and high serum CPK is
frequent finding

11. EtiologyEtiology
 Plasma volume contraction.
 Tissue hypoxia
 Hyponatremia.
 Hypomagnesemia.
 Carnitine deficiency.
 High serum leptin level

12. TreatmentTreatment..
 Treatment is directed at two goals:
Reducing the frequency of cramps.
Relieving symptoms when they occur.

13. Interventions to reduce the frequency ofInterventions to reduce the frequency of
crampscramps
 Prevention of dialysis-associated hypotension.
 The use of high concentrations of sodium in
the dialysate.
 Carnitine supplementation
 Administration of quinine that decrease the
excitability of the motor end-plate to nerve
stimulation and increase muscle refractory
period, thereby preventing prolonged
involuntary muscle contraction

14. OthersOthers
 Minimize inter-dialytic weight gain, will
avoid plasma volume contraction and hypo-
osmolality that occur with high rate of
ultrafiltration required to achieve the patient
dry weight during dialysis session
 Some medication includuing short acting
benzodiazepines (eg, oxazepam), nifidepine,
phynetoin, carbamezapine, amitryptalyin, and
gabapentin may be used.

15. Treatment of cramp during HD
 Despite preventive measures, cramp
on dialysis remain a common
problem.
 Reversal of low blood pressure is the
most important.
 Hypertonic saline versus dextrose.
 Mannitol

16. CHEST PAINCHEST PAIN
Chest pain occurs during dialysis could be:
 associated with hypotension
 DDS
 Angina
 Hemolysis
 Air or pulmonary embolism (rare).
The decision to continue or stop the dialysis
because of chest pain is based upon clinical
findings, such as hemodynamic stability, and the
results of the history and physical examination.

17. AnginaAngina
 Should always be considered as
those patients at an increased risk
of coronary disease.
 The appropriate history, physical
examination, and, if clinically
indicated, electrocardiogram and
cardiac enzyme evaluation should
therefore be performed.

18. ConCon’’t anginat angina
 If dialysis is continued, the administration
of oxygen and aspirin, reduction of the
desired ultrafiltration and/or blood pump
speed.
 Administration of nitrates or morphine
should be considered on an individual
basis.
 Angina during dialysis may be prevented
with the administration of nitrates and/or
beta blockers prior to the treatment.

19. HemolysisHemolysis
 May present as chest pain and tightness, or back pain
and If it is not recognized early, severe hyperkalemia
may happen and lead to death.
Findings highly suggestive of hemolysis include:
 A port wine appearance of the blood in the venous line
 Complaints of chest pain, shortness of breath, and/or
back pain
 A falling hematocrit
 A pink color of the plasma in centrifuged specimens.

20. Causes of hemolysis during dialysis

21. Approach to suspected case of heamolysis

22. ConCon’’t hemolysist hemolysis
The initial treatment is to:
 stop dialysis immediately
 Clamp the blood lines (do not return the blood to
avoid hyperkalemia)
 prepare to treat hyperkalemia and the potentially
severe anemia
 hospitalization for observation since life-
threatening hyperkalemia may develop after
dialysis has been terminated.

23. Air embolismAir embolism
 Rare but fatal cause of chest pain and dyspnea
during dialysis. (Foam in the venous blood line
should rise the suspicion that air is entering the
dialysis system).
 Fortunately, air embolism is rare in HD patients,
in part because of the presence of air detector in
HD machines.
 Disconnection of connecting caps and/or blood
lines can also lead to air embolism in patients
being dialyzed with central venous catheters.

24. Venous air embolism in HD

25. ConCon’’t- Air embolismt- Air embolism
Symptoms of the air embolism
 Massive VAE manifest with chest pain, dyspnea
and syncope.
 Cerebral air embolism may cause blurry vision,
altered mental status, seizure or ischemic
stroke.
 Patient may develop hypotension and
tachycardia.

26. ConCon’’t- Air embolismt- Air embolism
Treatment of suspected air embolism includes:
 Clamping the venous line and stopping the blood pump
 Positioning of the patient on the left side in a supine
position with the chest and head tilted downward.
 Cardio-respiratory support
 The administration of 100 percent oxygen by either mask
or endotracheal tube
 The most important aspect of air embolism is prevention
by the adequate function of monitoring devices on
dialysis machines

27. Dialysis disequilibrium Syndrome (DDS)Dialysis disequilibrium Syndrome (DDS)
 CNS disorder described in dialysis patients
characterized by neurological symptoms of
varying severity that are thought to be due
primarily to cerebral edema.
 Usually occur in new patient started on
hemodialysis especially with high BUN.
 Other risk factor include sever metabolic
acidosis , extremes of age , presence of other
CNS diseases like seizure disorders.

28. PathogenesisPathogenesis
 The symptoms of DDS are caused by
water movement into the brain, leading to
cerebral edema. Two theories have been
proposed to explain why this occurs:
fall in intracellular pH.
a reverse osmotic shift induced by urea
removal .

29. Clinical ManifestationClinical Manifestation
 The classic DDS develops during or immediately
after hemodialysis. Early findings include
 Headache
 Nausea
 Disorientation
 Restlessness
 Blurred vision
 Asterixis
 More severely affected patients progress to
confusion, seizures, coma, and even death.

30. Differential DiagnosisDifferential Diagnosis
 Uremia
 Subdural hematoma
 CVA
 Meningitis
 Metabolic disturbances as
hyponatremia and hypoglycemia
 Drug induced encephalopathy

31. TreatmentTreatment
 In general, symptoms of DDS are
self-limited and usually resolve within
several hours.
 The management of mild non-specific
disequilibrium symptoms, such as
nausea, vomiting, restlessness,
and/or headache, is symptomatic.

32. ConCon’’t-t- TreatmentTreatment
 Dialysis is stopped in the patient with
seizures and coma.
 Severe DDS with seizures can be
reversed more rapidly by raising the
plasma osmolality with either 5 mL of
23 percent saline or 12.5 g of
hypertonic mannitol.

33. Preventive strategies for DDS in
high-risk patients

34. Seizures in dialysis patients
 Seizures are not uncommon in HD patients.
 Seziures are more frequent in those who
require acute dialysis for severe uremia.
 Seizures activities tend to occur during or
shortly after dialysis.
 Preventive measures should be initiated in
patients with predisposing factors as extreme
uremia or severe electrolyte abnormalities.

35. Causes of seizures
 Uremic encephalopathy
 DDS
 Drugs as EPO
 Hemodynamic instability
 Cerebrovascular disease
 Dialysis dementia due to aluminum intoxication.
 Electrolyte disorders
 Alcohol withdrawal
 Air embolism

37. Prevention of seizures
Prevention of seizures in HD patients involve
recognition and amelioration of risk factors:
 Uremic encephalopathy
 DDS
 Rapid acid-base and osmolality changes
 Hypoxia and hypotension
 Anticoagulation with intracranial bleeding
 Hypertensive crisis induced by EPO
 Removal of anticonvulsant medication during
dialysis

38. Treatment
The emergency treatment of seizures in
dialysis patients include the following:
 Stop dialysis
 Securing a patent airway
 Stabilizing the circulation

39. Cont, treatmentCont, treatment
 Blood should be sampled for serum level of
glucose and electrolytes
 Benzodiazepine should be administered as
5-10 mg of diazepam by slow IV push. The
dose can be repeated at 5 minute interval to
a maximum dose of 20-30 mg.
 Initial diazepam therapy may be followed by a
loading dose of phenytoin with continuous
ECG monitoring

40. Dialysis Reactions
 During HD blood is exposed to surface
components of extracorporeal circuit as
dialyzer, tubing and other foreign
substances.
 This interaction between patient blood and
extra-corporeal system can lead to various
adverse reaction.

41. Dialysis reactions

42. Acute event during HD

43. Thank you