Dialysis complications

Background

  • Dialysis patients are high-acuity ED patients with unique complications
  • Common presentations: access problems, hypotension, electrolyte emergencies, infections
  • Always check when last dialysis session was and if any were missed

Hemodialysis Complications

Dialysis Complications

Access Complications

  • Thrombosed fistula/graft: absent thrill/bruit → vascular surgery referral within 24-48h
  • Hemorrhage from access site: direct pressure x 10-15 min; avoid tourniquet proximal to access
  • Infection: erythema, warmth, purulent drainage → blood cultures + empiric vancomycin; avoid using infected access
  • Steal syndrome: hand ischemia distal to fistula (pain, pallor, cool fingers) → vascular surgery

AV Fistula Complications

During/Post-Dialysis

  • Hypotension: most common acute complication; give NS bolus (avoid excessive fluid in volume-overloaded patient)
  • Dysequilibrium syndrome: headache, N/V, AMS, seizures during/after dialysis (especially first sessions) — diagnosis of exclusion after ruling out other AMS causes
  • Air embolism: rare but catastrophic; place in left lateral decubitus/Trendelenburg
  • Muscle cramps: NS bolus, reduce ultrafiltration rate

Missed Dialysis

  • Hyperkalemia: most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
  • Volume overload / pulmonary edema: BiPAP, nitroglycerin, furosemide (limited efficacy in anuric patients), emergent dialysis
  • Uremic pericarditis: friction rub, emergent dialysis; avoid anticoagulation (hemorrhagic risk)
  • Metabolic acidosis

Peritoneal Dialysis Complications

  • Peritoneal dialysis-associated peritonitis: cloudy effluent, abdominal pain, fever
    • Send peritoneal fluid for cell count, Gram stain, culture
    • Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
  • Catheter malposition, obstruction, leakage
  • Exit site/tunnel infection: erythema, drainage at catheter site

Altered Mental Status in Dialysis Patients

ESRD Associated Skin Conditions

Cardiovascular

Evaluation

  • ECG (hyperkalemia changes — peaked T waves, widened QRS)
  • BMP: K, Ca, BUN, Cr, glucose
  • CBC, blood cultures if febrile
  • CXR: pulmonary edema, line placement
  • Access exam: check thrill/bruit

Disposition

  • Low threshold for admission — these are high-risk patients
  • Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
  • Arrange emergent dialysis for: severe hyperkalemia, pulmonary edema, uremic pericarditis
  • Discharge only for minor issues with ensured follow-up at dialysis center

See Also

References

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