What are the guidelines for managing hemodialysis complications?

Hemodialysis Complications: Management Guidelines

I cannot provide Philippine Society of Nephrology-specific guidelines as none were included in the evidence provided. However, I can present internationally recognized guidelines for managing hemodialysis complications that are widely applicable.

Vascular Access Complications

The primary strategy for preventing vascular access complications is maximizing native arteriovenous (AV) fistula placement, with at least 50% of new hemodialysis patients receiving a primary AV fistula as their initial access. 1

Access Type Selection and Hierarchy

• Native AV fistulae should be the first choice for permanent vascular access, as they demonstrate the best 4-5 year patency rates and require the fewest interventions compared to synthetic grafts or catheters 1
• Synthetic AV grafts should be considered only when native fistulae are not feasible 1
• Tunneled dialysis catheters should be used as a last resort for long-term access due to higher complication rates 2

Temporal Risk Profile for Access Complications

• The highest risk period for both infectious and noninfectious complications occurs in the first 3-6 months after access placement or remedial procedures, with hazards 5-10 times greater than later periods 3
• Prevention strategies should specifically target this early high-risk window 3
• Risk decline occurs more rapidly with fistulae compared to grafts and catheters 3

Monitoring and Surveillance Program

Every dialysis center must implement an organized monitoring and surveillance program with regular clinical assessment to detect access dysfunction before thrombosis occurs. 1

Physical Examination Components:

• Assess for adequate blood flow from vascular access 1
• Monitor for access recirculation, which reduces effective clearance 1
• Evaluate for hemodynamically significant stenosis through physical examination 1
• Check for pseudoaneurysm development in grafts 1
• Document all findings systematically 1

Specific Complications and Management

Pseudoaneurysm of AV Grafts:

• Avoid needle insertion into pseudoaneurysm areas 1
• Surgical resection with interposition graft is indicated when:
  • Rapid expansion occurs 1
  • Size exceeds twice the graft diameter 1
  • Overlying skin viability is threatened 1
  • Infection is present 1

Aneurysm of Native AV Fistulae:

• Surgical intervention required only when the aneurysm involves the arterial anastomosis 1
• Venipuncture should avoid the aneurysm due to hemostasis risks 1

Catheter-Related Bacteremia:

• Bacteremia with tunnel tract involvement requires catheter removal 1
• Three weeks of systemic antibiotic therapy is necessary for catheter-associated bacteremia 1
• New permanent access should not be placed until cultures remain negative for at least 48 hours after antibiotic cessation 1

Intradialytic Complications

Inadequate Dialysis Delivery

Common factors compromising delivered dialysis dose include access recirculation, inadequate blood flow, dialyzer clotting, equipment calibration errors, and treatment time reductions. 1

Compromised Urea Clearance:

• Access recirculation reduces concentration gradient in the dialyzer 1
• Inadequate blood flow from vascular access 1
• Dialyzer clotting reduces effective surface area 1
• Blood pump/dialysate flow calibration errors 1
• Dialyzer leaks 1

Treatment Time Reductions:

• Clinical complications during sessions (equipment alarms, fistula needle manipulation, pump failure) interrupt continuous treatment 1
• Premature discontinuation for staff convenience or patient request 1
• Patient tardiness delays session initiation 1
• Incorrect time documentation 1

Symptomatic Hypotension and Cramps

Without compromising dialysis adequacy, implement strategies to minimize intradialytic hypotension and cramps, as these complications lead to premature treatment termination and reduced delivered dose. 1

Evidence-Based Prevention Strategies:

• Avoid excessive ultrafiltration 1
• Slow the ultrafiltration rate 1
• Perform isolated ultrafiltration 1
• Increase dialysate sodium concentration 1
• Switch from acetate to bicarbonate-buffered dialysate 1
• Reduce dialysate temperature 1
• Administer midodrine predialysis 1
• Correct anemia to recommended ranges 1
• Administer supplemental oxygen 1

Laboratory Sampling Errors

Proper blood sampling technique is critical for accurate dialysis adequacy assessment. 1

Common Sampling Errors:

• Predialysis sample dilution with saline falsely lowers BUN and overestimates delivered dose 1
• Drawing predialysis sample after dialysis initiation underestimates true BUN 1
• Drawing postdialysis sample before treatment completion overestimates BUN 1
• Drawing postdialysis sample more than 5 minutes after dialysis captures urea rebound, significantly elevating BUN 1
• Laboratory calibration or equipment problems 1

Quality Assurance Requirements

Each dialysis center must establish a comprehensive database tracking access types created, complication rates, and outcomes as part of continuous quality improvement. 1

• Track all access-related hospitalizations 1
• Monitor access patency rates by type 1
• Document all interventions required to maintain patency 1
• Implement staff and patient education programs on access care 1

Patient Re-evaluation

Patients should be re-evaluated for possible native AV fistula construction after every dialysis access failure. 1

This systematic approach maximizes the opportunity for optimal access placement throughout the patient's dialysis course 1.