Complications duringHemodialysis

Dr forghani . MD

Complications duringHemodialysis

• INTRADIALYTIC HYPOTENSION• MUSCLE CRAMPS• NAUSEA AND VOMITING• HEADACHE• CHEST PAIN AND BACK PAIN• ITCHING• DISEQUILIBRIUM SYNDROME• DIALYZER REACTIONS• HEMOLYSIS• AIR EMBOLISM

INTRADIALYTIC HYPOTENSION

MECHANISM•IDH related to blood volume changes•Hypotension related to lack of vasoconstriction•Hypotension related to cardiac factors

Definition and Importance: SBP < 90 mmHg or decreased 20-30 mmHg during HDDistressing symptom and poor out come Common in patient with predialysis low blood pressure

INTRADIALYTIC HYPOTENSION

IDH related to blood volume changes

1. Avoid large interdialytic weight gains (fluid intake limitation)2. Increasing weekly treatment time and frequency3. Maintaining and increasing urinary volume4. Choose target weight carefully5. Use an appropriate dialysis solution sodium level

Can be limited IDH with prevention of large blood volume change

Low Na solution induced IDH ( decreased blood volume) VS high Na solution that induced HTN , IDWG and Thirststarting with Na 145-155 then decreased to 135-140

Hypotension related to lack of vasoconstriction Decreased total peripheral resistance (TPR)

(arterial pressure shift to Vein)

1. Lower dialysis solution temperature (35.5-36)

2. Avoid intradialytic food ingestion (splanchnic vasodilation)

3. Minimize tissue ischemia (due to anemia HCT<25 and hypotension increase

Adenosine) during dialysis transfusion can be useful4. Midodrine ( alpha agonist 10 mg 1h pre HD)

5. Sertraline (4-6 week administration improve autonomic function)

6. Antihypertensive medication (after HD , decrease or D/C )

7. Dialysis fluid potassium level (higher K solution)

8. Fludrocortisone (in adrenal insufficiency)

9. Vasopressin (constricts splanchnic vessels)

INTRADIALYTIC HYPOTENSION

Hypotension related to cardiac factors• Diastolic dysfunction is common (stiffness and hypertrophy decrease

filling pressure and cardiac out put) improve with Verapamil

• Heart rate and contractility (compensatory mechanism dysfunction)

• Dialysis solution calcium (dialysate Ca 1.7 mm VS 1.25)

INTRADIALYTIC HYPOTENSION

Detection of hypotension (symptom and sign, regular BP measurement Q1h or 30 min)

Management of IDH ( position, saline 0.9, hypertonic saline increase vasopressin, albumin, glucose, mannitol infusion, decrease or off UF, decrease BFR when we use acetate)

Strategy to Help Prevent Hypotension During Dialysis

MUSCLE CRAMPSEtiology: high prevalence in 1th month of HD starting

(hypotension, hypovolemia, high UF, low Na dialysate) induced vasoconstriction followed by hypo perfusion, abnormal muscle relaxation occur. Other cause hypocalcaemia, hypomagnesaemia hypokalemia, low cardiac index, low K and Ca dialysate

Management (saline, glucose , mannitol, nifedipine ,muscle stretching)

Prevention • Stretching exercises• Dialysate sodium• Dialysate magnesium• Biotin• Carnitine, oxazepam, and vitamin E• Quinine

NAUSEA AND VOMITING

• Etiology and incidence (10% during HD)

Multifactorial,(often during hypotension episode, disequilibrium syndrome, dialyzer reaction, gastroparesis)

• Management (hypotension management, antiemetic metoclopramide)

• Prevention (hypotension avoidance)

HEADACHE• Etiology (70% during HD)Disequilibrium syndrome, caffeine withdrawal, HD predispose migraine

head ache

• Management ( acetaminophen during HD)

• Prevention (Coffee during HD , change Dialysate Na)

CHEST PAIN AND BACK PAIN 1-4%, unknown cause; R/O Angina, air emboli, pericarditis, hemolysis; change dialyzer can be helpful

ITCHING Sometimes precipitated or

exacerbated by HD ETIOLOGY: low grade

hypersensitivity to dialyzer or blood circuit , hepatitis, scabies

TREATMENT:• moisturizing• dialysis adequacy• hyperparathyroidism • hyperphosphatemia treatment• antihistamin• charcoal• Gabapentin• Nalfurafine central KOA

DISEQUILIBRIUM SYNDROME• Definition (include neurologic and systemic symptoms during or after HD)Nausea ,vomiting, restlessness, head ache, seizure, coma

• Etiology (brain edema, CSF PH change)

• Management:

• Prevention: In acute HD :URR 40% in first HD, Dialysate Na near to plasma NaIn chronic HD: Dialysate Na 140, high Na 145-150 that declines over

the course of HD

• Mild disequilibrium symptomatic, decrease BFR or solute removal and avoid PH severe change, HD discontinuation

• Severe disequilibrium HD discontinuation, saline, mannitol

DIALYZER REACTIONSType A (anaphylactic type)

Manifestations mild : pruritus, urticaria, cough, coryza, sneezing, diarrhea, abdominal crampSevere: impending doom, dyspnea, feeling warmth at AVF or body, cardiac arrest, death

Etiology

Management: blood line clamp, HD d/c, cardiopulmonary support, antihistamine, steroid, epinephrinePrevention: ethylene oxide change to gamma radiation, after R/O other causes heparin can be D/C, ACEI d/c in AN69 dialyzer use

Ethylene oxideContaminated dialysis solution (bacteria and endotoxin , symptomatic In first 2 minutes) Heparin: (urticaria , nasal congestion, anaphylaxis)

Nonspecific type B dialyzer reactions

• Symptoms: back pain and chest pain 20-40 minute past HD starting, less severe than type A,

• Etiology unknown, possibly complement activation

• Management O2 , R/O angina, HD can be continued, symptoms often abate after 1 h.

• Prevention trying a different dialyzer

Air emboli

• Manifestation is potential catastrophe

Symptoms:

Sign: foam in venous line, churning sound

• Etiology: arterial needle and prepump air entry, inadvertently opened Catheter

• Management: venous line clamp, pump stop, recumbent position, O2, resuscitation, ventricular air aspiration

in seated position, LOS, seizure, deathIn recumbent: dyspnea, cough, arrhythmia, chest tightness

HEMOLYSIS

• Manifestation: chest pain, dyspnea, back pain, muscle weakness due to hyperkalemia

• Etiology: obstruction or narrowing in blood line, G6PD, dialysate overheated, hypotonic, contamination with chloramine (city water)

• Management: D/C Blood pump, hyperkalemia treatment, transfusion, observed carefully