Complications of Dialysis
Dialysis patients face numerous acute and chronic complications that significantly impact morbidity and mortality, with infection, cardiovascular events, and vascular access problems being the most critical concerns requiring vigilant monitoring and management.
Acute Complications
Hemodialysis (HD)
Intradialytic hypotension is the most common acute complication, occurring in approximately 25% of HD sessions 1. This is exacerbated by ultrafiltration rates >1000 mL/h and diabetes 1. Hypotension during dialysis increases dysrhythmogenic risk and can precipitate cardiac ischemia, particularly dangerous given that dialysis patients have underlying coronary disease in many cases 2.
Muscle cramps affect 22% of sessions, associated with rapid ultrafiltration and longer dialysis duration 1. Hypertensive crisis occurs in 14% of sessions 1.
Cardiac dysrhythmias represent a life-threatening acute complication. Ventricular dysrhythmias occur in 76% of maintenance HD patients, with potentially life-threatening ventricular dysrhythmias and silent myocardial ischemia noted in 29% and 36% respectively during the peri-dialysis period 2. The risk stems from:
- Rapid electrolyte shifts (potassium, calcium, magnesium)
- Volume fluctuations
- Underlying left ventricular hypertrophy (present in 80% of dialysis patients)
- QTc prolongation 2
Dialysis disequilibrium syndrome occurs from rapid solute removal causing cerebral edema, potentially fatal if occurring during understaffed periods 1.
Bleeding complications occur in 64% of cases at the vascular access site, with three deaths reported from bleeding in one series 1.
Peritoneal Dialysis (PD)
Peritonitis remains the most significant acute complication. With modern techniques, rates can be as low as 0.5 episodes per patient-year, though combined with exit site infections, total access complications approach one episode per patient-year 3. Importantly, bacteremia is rare with PD-related infections compared to HD access infections 3.
Peritoneal leakage into subcutaneous tissues, pleural space (hydrothorax), or genitalia causes pain, respiratory compromise, and inadequate dialysis 4.
Acute volume intolerance manifests as abdominal pain, dyspnea, or appetite loss from increased intra-abdominal pressure 4.
Chronic Complications
Cardiovascular Disease (Both Modalities)
Cardiovascular disease is the dominant chronic complication, present in approximately 62% of long-term dialysis patients with no significant difference between HD and PD 5. Specific manifestations include:
- Valvular disease (most common cardiac complication) 5
- Diastolic dysfunction
- Left ventricular hypertrophy
- Ischemic heart disease
- Congestive heart failure 5
Atrial fibrillation is more common in dialysis patients than the general population 2. New-onset dysrhythmias increase over time in PD patients, with ventricular dysrhythmias rising from 30% to 43% and supraventricular dysrhythmias from 40% to 57% over 20 months 2.
Vascular Access Complications (HD)
Access stenosis from neointimal hyperplasia is the primary cause of access failure 6. Stenoses occur most commonly at the vein-graft anastomosis (AVG) or juxta-anastomotic region (AVF), though can develop anywhere in the circuit 6.
Access thrombosis is the leading cause of access loss, associated with increased healthcare costs and compromised quality of life 6.
Limb ischemia (steal syndrome) requires urgent evaluation, particularly in high-risk groups (diabetics, elderly, multiple access attempts). Monitor for coldness, numbness, tingling, motor impairment, and reduced distal pulses 7.
Infection of vascular access leads to bacteremia and sepsis in a high percentage of cases, more severe than PD-related infections 3. Staphylococcus aureus is the leading pathogen, with 50-60% nasal carriage rates in HD patients 7.
Peritoneal Membrane Complications (PD)
Ultrafiltration failure develops in high transporters due to rapid glucose absorption, often accompanied by excessive protein losses 4.
Encapsulating peritoneal sclerosis is a rare but serious late complication 8.
Protein malnutrition from peritoneal protein losses (typically 5-15 g/day, higher with peritonitis) 4.
Metabolic and Bone Complications (Both Modalities)
Secondary hyperparathyroidism with parathyroid adenoma development occurs in approximately 14% of long-term patients, with 10% requiring parathyroidectomy 5. Serum phosphate and iPTH levels are significantly higher in HD patients 5.
Acquired cystic kidney disease develops in approximately 48% of patients on dialysis >10 years, with equal prevalence in HD and PD 5.
Hypocalcemia is associated with increased mortality, cardiac ischemic events, and congestive heart failure 9.
Neurological Complications (Both Modalities)
Uremic peripheral neuropathy affects approximately 48% of long-term dialysis patients (>10 years), with no difference between modalities 5. Presentations include:
- Mixed sensory-motor neuropathy (most common)
- Demyelinating neuropathy
- Axonal neuropathy
- Carpal tunnel syndrome 5
Gastrointestinal Complications
Cirrhosis, pancreatitis, GI bleeding, and gastric ulcer risk is significantly higher in HD 10.
Gastroesophageal reflux disease risk is significantly elevated in PD patients 10.
Diverticulitis during PD frequently results in peritonitis; patients with frequent episodes should be switched to HD 4.
Psychological Complications (Both Modalities)
Depression affects a substantial proportion of dialysis patients, associated with nonadherence, poorer quality of life, more frequent hospitalizations, and higher mortality 8, 11.
Anxiety affects approximately 40% of dialysis patients 8.
Critical Pitfalls to Avoid
Timing of dialysis post-acute coronary syndrome: Collaborate between nephrology and cardiology to balance volume/electrolyte management against bleeding risk and hemodynamic instability in the first 48 hours 2.
Understaffing during high-risk periods: 67.7% of acute HD complications occur during understaffed nighttime shifts, including all four deaths in one series 1.
Inadequate infection prevention: Failure to use surgical masks for patients and staff during catheter access, improper hub sterilization (require 3-5 minutes povidone-iodine soak), and inadequate exit site care increase infection risk 7.
Missing limb ischemia: High-risk patients (diabetic, elderly, multiple access attempts) require close monitoring for 24 hours post-access creation and monthly thereafter for coldness, sensory changes, and motor impairment 7.
Ignoring dysrhythmia risk: All dialysis patients require baseline 12-lead ECG at dialysis initiation; treat dysrhythmias as in the general population with attention to drug dosing adjustments 2.