What are the complications of dialysis?

Complications of Dialysis

Dialysis complications span a broad spectrum including vascular access problems, infections, cardiovascular events, intradialytic hypotension, symptom burden affecting quality of life, and metabolic disturbances—with infection and cardiovascular complications being the leading causes of morbidity and mortality.

Major Complication Categories

Vascular Access Complications

Vascular access remains the most common source of morbidity in hemodialysis patients 1:

• Thrombosis: Most frequent complication, typically due to intimal hyperplasia at the venous anastomosis
• Stenosis: Progressive narrowing requiring surveillance and intervention
• Infection: Particularly problematic with tunneled catheters (see below)
• Central venous stenosis: Can compromise future access options
• Steal syndrome: Arterial insufficiency causing hand ischemia
• Ischemic monomelic neuropathy: Acute nerve injury from hypoperfusion
• High-output cardiac failure: From excessive AV fistula flow
• Aneurysmal degeneration: Risk of rupture with repeated cannulation

Infectious Complications

Bloodstream infections (BSIs) are a major cause of hospitalization and death in dialysis patients 2. The risk hierarchy by access type is:

• Tunneled catheters: Highest infection risk
• AV grafts: Intermediate risk
• AV fistulas: Lowest infection risk

Prevention strategies that reduce BSI rates include 2:

• Hand hygiene observation and compliance monitoring
• Vascular access care observation protocols
• Alcohol-based chlorhexidine for catheter exit site antisepsis during dressing changes
• Catheter hub disinfection with antiseptic at every access and disconnect
• Monthly microbial testing of dialysis water and dialysate

Water quality issues can cause pyrogenic reactions ranging from chills and fever to septicemia with severe hypotension and shock 2.

Influenza poses particular risk—dialysis patients are more susceptible to contracting influenza and experiencing severe complications. Treatment requires oseltamivir 30 mg initially, then 30 mg at each dialysis session for 5 days 2.

Cardiovascular Complications

The cardiovascular risk in dialysis patients is 10 to 20 times higher than the general population 3. Key mechanisms include:

• Intradialytic hypotension (IDH): Occurs in almost 8% of hemodialysis sessions, defined as nadir systolic BP <90 mmHg with intradialytic decline >30 mmHg 4
• Myocardial stunning: Caused by aggressive ultrafiltration and blood pressure variability
• Cardiac arrhythmias: Related to electrolyte shifts and volume changes
• Endothelial dysfunction: Aggravated by both inflamed kidneys and the dialysis process itself

IDH is associated with increased risk for death and can be reduced by 20-68% with intensive hemodialysis schedules 4.

Symptom Burden and Quality of Life Impact

The 2023 KDIGO guidelines emphasize that symptom-based complications are severely underrecognized and undertreated 5. Critical findings include:

• High discordance: Only half of hemodialysis patients with bone pain receive analgesia; less than a quarter with sleep disturbance receive sleeping aids 5
• Recovery time: In the DOPPS study, 41% of patients required 2-6 hours to recover after dialysis, and 27% needed >6 hours—recovery time was linearly associated with increased risks for death and hospitalization 4
• Patient priorities: Patients identify decreases in blood pressure and feeling washed out or drained as more important outcomes than death or hospitalization 4

KDIGO consensus recommendations mandate 5:

• Clinicians must assess symptoms most important to individual patients
• Prioritization should be based on patient perceptions of which symptoms most negatively impact their ability to live the life they want
• Nephrology multidisciplinary teams should take the lead in symptom management with holistic care as the goal
• Regular global symptom screening using both open-ended questions AND standardized patient-reported outcome measures (PROMs)

Dialysis Disequilibrium Syndrome

This acute complication occurs from rapid solute shifts, particularly in new dialysis patients, causing cerebral edema with headache, nausea, confusion, and potentially seizures 6.

Peritoneal Dialysis-Specific Complications

• Peritonitis: Principal complication requiring antibiotic therapy
• Tunnel infection: May necessitate catheter removal
• Catheter malfunction: Obstruction or migration

Common Pitfalls

The most critical pitfall is the historical focus on laboratory targets and mortality rather than patient-reported symptoms 5. This leads to:

• Patients perceiving that communicating symptoms to their dialysis team is of limited usefulness
• Undertreatment of pain, sleep disturbance, fatigue, and other quality-of-life impacting symptoms
• Failure to recognize that symptom impact on functioning can be more important to patients than symptom frequency or severity

Another major pitfall is inadequate vascular access surveillance, leading to preventable thrombosis and loss of access sites 1.