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Recurrent hemodialysis has become a successful form of therapy for patients with end-stage chronic renal failure.Dialysis therapy for end-stage renal disease was firstsuccessully attempted by Scribner and associates in 1960.Subsequently numerous other investigators have reported ondialysis in chronic uremia with varying degrees of success.http://www.annals.org/content/64/2/293.short, hemodialysis : asuccessful therapy or chronic uremia, Annals of Internal Medicine, Jeryy P.Pendras and R.V. Erickson, 1st February 1996.http://www.nejm.org/doi/pdf/10.1056/NEJMc081598 frequency can be found in the journal belowhttp://www.nature.com/ki/journal/v60/n3/abs/4492525a.html 

Outcome of Patients on Dialysis

The mortality rate of dialysis patients is approximately 20% despitecareful attention to fluid and electrolyte balance or other treatment.More than 30% of patients who begin dialysis die within the first year of the initiation of treatment. The most common cause of sudden death inpatients with ESRD is hyperkalemia, which is often encountered inpatients after missed dialysis or dietary indiscretion. In addition, thecardiovascular mortality is 10-20 times higher in dialysis patients than inthe normal population. All-cause mortality in dialysis patients older than65 years is more than 6 times the general population.[3]

The morbidity and mortality of dialysis patients is much higher in theUnited States compared with most other countries, which s is probablya consequence of selection bias. Due to liberal criteria for receivinggovernment-funded dialysis in the US and rationing (both medical andeconomic) in most other countries, US patients receiving dialysis are onthe average older and sicker than those in other countries.

Electrolyte Abnormalities

Electrolyte abnormalities may result from renal disease itself or as aniatrogenic complication.

Hyperkalemia

Hyperkalemia is the most common clinically significant electrolyteabnormality in chronic renal failure. This condition is uncommon whenpatients with end-stage renal disease (ESRD) are compliant withtreatment and diet, unless an intercurrent illness such as acidosis or sepsis develops. A history of hyperkalemia requiring treatment or poor compliance with treatment should lower the threshold for ordering apotassium level.

Serum potassium levels usually should be measured in patients withchronic renal failure or ESRD who present with a systemic illness or 

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major injury. Serum potassium rises when the serum is acidemic, eventhough total body potassium is unchanged. Hyperkalemia is usuallyasymptomatic and should be treated empirically when suspected andwhen arrhythmia or cardiovascular compromise is present.

Electrocardiography (ECG) may be useful in diagnosis of suspectedhyperkalemia. Severely peaked T waves are a relatively specific finding,although this is not a very sensitive test for hyperkalemia in the settingof chronic renal failure. Widening of the QRS complex indicates severehyperkalemia and must be treated aggressively and rapidly. Similar "hyperacute" T-waves may be seen early in acute MI.

Hyponatremia, hypocalcemia, and hypermagnesemia

Iatrogenic complications related to fluid administration (fluid overload) or 

medications are frequently encountered in patients in renal failure.Dilutional hyponatremia may cause mental status changes or seizures.Hypocalcemia or hypermagnesemia may cause weakness and life-threatening dysrhythmias. Neuromuscular irritability is seen withhypocalcemia and may present as tetany or paresthesia.Hypermagnesemia causes neuromuscular depression with weaknessand loss of reflexes. Acidosis may present as shortness of breath due tothe work of breathing from compensatory hyperpnea.

Dialysis Dysequilibrium Syndrome

Dialysis dysequilibrium syndrome is a common neurologic complicationseen in dialysis patients that is characterized by weakness, dizziness,headache, and in severe cases, mental status changes. The diagnosisis one of exclusion; a prime characteristic of this syndrome is that it isnonfocal.

Infection

Patients with an arteriovenous fistula or graft should have the siteexamined regularly. Vascular access problems include infections, whichare usually manifest with typical signs and symptoms such as localpain, redness, warmth, or fluctuance. Fever may be present withoutlocal signs. Clotting of the vascular access presents as loss of normalbruit or palpable thrill. There may be signs or symptoms of distal limbischemia.

CAPD-associated peritonitis

Peritonitis is common in patients who are being treated with CAPD,occurring approximately once per patient year. Patients present withgeneralized abdominal pain, which may be mild, or complain of a cloudy

effluent. Localized pain and tenderness suggest a local process, suchas incarcerated hernia or appendicitis. Severe generalized peritonitis

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may be due to a perforated viscus as in any other patient. Fever is oftenabsent.

The diagnosis of CAPD-associated peritonitis is confirmed by culture of effluent dialysate (ie, peritoneal fluid), which should be ordered before

empiric treatment. Presumptive diagnosis is based on a peritoneal fluidwhite blood cell (WBC) count of greater than 100/mL or a positive Gramstain. The effluent is often cloudy when peritonitis is present, and thisappearance accurately predicts elevated WBC counts. In patientswithout peritonitis, WBC counts of 0-50/mL with a mononuclear predominance are considered normal. Cell counts are usually muchhigher with predominant polymorphonuclear neutrophils (PMNs) whenperitonitis is present.

Hemorrhage

Patients may present after dialysis or minor trauma with bleeding fromtheir vascular access site. Active bleeding can also occur from theincisional wound of a newly placed fistula or graft. The bleeding canusually be controlled with elevation and firm but nonocclusive pressure.In the immediate postdialysis period, protamine may be needed toreverse the effect of heparin (routinely used in dialysis to preventclotting). Note that life-threatening bleeding may occur.

 Anemia is inevitable in chronic renal failure because of loss of erythropoietin production. Abnormalities in white cell and plateletfunctions lead to increased susceptibility to infection and easy bleedingand bruising. This condition results in fatigue, reduced exercisecapacity, decreased cognition, and impaired immunity.

Vascular access aneurysms or pseudoaneurysms

 Aneurysms or pseudoaneurysms may form and progressively enlarge tocompromise the skin overlying the site of venous access. These presentas localized swelling, which may be pulsatile, and are often chronic. Arapid increase in size may indicate active bleeding.

Treatment and Management Considerations

Peripheral hemodialysis access sites may be used to draw blood or infuse medications and fluids in an emergency when no other access isavailable. A central venous access device may be used with the usualprecautions. In an immediately life-threatening emergency, the followingprocedure may be used. The site should not be used for routineintravenous access.

Do not use a tourniquet.

 Avoid puncturing the back wall of the vessel.Carefully secure all intravenous (IV) catheters; infusions may need to

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be under pressure because of relatively high pressures at theaccess site.

 Apply firm but nonocclusive pressure for 10-15 minutes after accessing a peripheral hemodialysis access site.

Document presence of a thrill before and after procedure.Consider consultation with a nephrologist and/or vascular surgeon for the following problems:

Need for urgent dialysis

Significant deterioration from baseline renal function

CAPD-associated peritonitis or catheter-associated infection

Infection, obstruction, or expanding aneurysm/pseudoaneurysm of thevascular access

Other problems that may arise in the dialysis patient include the

following:

Changes in calcium and phosphorus metabolism, acidosis

Lipid disorders

Pericarditis

Serositis

Gout, pseudogout

Hypothyroidism, seizures, fractures

 Accelerated hypertension

Infertility, impotence, spontaneous abortion

Bleeding, gastrointestinal mucosal ulcerations, arteriovenousmalformations

Hypotension and Shock

Hypotension in dialysis patients may be due to any of the causesencountered in any other patient. Consider serious causes such asbleeding, cardiac dysfunction, and sepsis. While ruling out more seriouscauses, IV isotonic saline in small bolus doses (approximately 200 mL)may be used for treatment.

IV fluids should not be administered except for cases of frank shock.When used, the preferred regimen is small bolus doses (approximately200-250 mL) with reevaluation for effect between doses. LactatedRinger solution should not be used because of the potassium content.

Cardiac Dysfunction

Cardiac arrest in a patient with chronic renal failure or ESRD may bedue to hyperkalemia. Consider treatment with IV calcium and IVbicarbonate while awaiting laboratory confirmation. Nebulized albuterolmay also be used for temporary lowering of serum potassium levels,

when appropriate.

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Consider pericardial tamponade, especially in the setting of pulselesselectrical activity (PEA). If tamponade is suspected, consider pericardiocentesis.

Nitrates (oral or topical) can be temporarily effective for patients with

fluid overload.

Hemorrhage

Bleeding may be due to uremic coagulopathy or from anticoagulationduring hemodialysis. In the latter case, the heparin effect may bereversed with protamine. Desmopressin (DDAVP) by nasal,subcutaneous, or IV routes and cryoprecipitate are effective incorrection of uremic coagulopathy. Applying firm but nonocclusivepressure for 10-15 minutes best treats bleeding from a vascular accesssite.

Infection and Peritonitis

CAPD-associated peritonitis is often treated with a loading dose of parenteral antibiotic, followed by a period of intraperitoneal antibiotics. Asystematic review found that IV antibiotics are not needed.[2] Institutionsthat treat CAPD patients may have a standard protocol for treatment. Inmost cases, the patient's nephrologist should be consulted, especially if there is no institutional consensus on optimal treatment. When there isalso evidence of local infection around the catheter, systemic antibiotics

should be used.

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