What are the potential complications of dialysis and how can they be managed?

Dialysis Complications and Management

Dialysis complications fall into three major categories: vascular access-related problems (thrombotic, nonthrombotic, and infectious), intradialytic emergencies, and chronic systemic complications—all requiring proactive surveillance and prompt intervention to prevent mortality and preserve quality of life. 1

Vascular Access Complications

Thrombotic Flow-Related Complications

Stenosis is the primary precipitator of vascular access failure and must be identified early through systematic monitoring. 1

• Stenosis ≥50% of lumen diameter requires intervention when associated with: 1

  • Previous thrombosis in the access
  • Elevated venous dialysis pressure
  • Abnormal recirculation measurements
  • Unexplained decrease in dialysis dose (Kt/V)
  • Decreasing access flow rates

• Physical examination detects 90% of clinically significant access problems through: 1

  • Changes in access thrill or bruit
  • Prolonged bleeding after decannulation
  • Arm swelling
  • Difficulty achieving prescribed blood flow rates

• Percutaneous transluminal angioplasty is first-line treatment for stenosis, with surgical revision reserved for patients requiring angioplasty more than twice within 3 months 1

• Access thrombosis is the primary cause of vascular access loss and directly increases healthcare costs while compromising quality of life 1

Nonthrombotic Flow-Related Complications

• Steal syndrome presents with hand ischemia, pain, and tissue loss due to arterial blood diversion through the access 1

• Aneurysm formation at cannulation sites can compromise overlying skin, leading to incomplete hemostasis, graft rupture, severe hemorrhage, and potential exsanguination and death 1

• Rope-ladder (step-ladder) cannulation technique is critical to prevent aneurysm formation and vessel damage, while general area cannulation should be avoided 2

Infectious Complications

• Access-related infections involve intraluminal, extraluminal, or peri-access tissues including cannulation sites and provoke clinically significant infectious symptoms 1

• Regular surveillance and prompt treatment of access infections is essential to prevent sepsis and access loss 2

Intradialytic Emergencies

Most hemodialysis emergencies are attributable to human error, with rare idiosyncratic reactions comprising the remainder. 3

Life-Threatening Emergencies

• Dialysis disequilibrium syndrome occurs from rapid solute shifts causing cerebral edema 3

• Venous air embolism can be fatal if air enters the bloodstream through access disconnection 3

• Hemolysis results from dialysate contamination or improper temperature/osmolality 3

• Venous needle dislodgement causes rapid exsanguination and requires immediate recognition 3

• Major allergic reactions to dialyzer membranes or treatment medications can cause anaphylaxis 3

Hemodynamic Complications

• Intradialytic hypotension is the most common acute complication, related to excessive ultrafiltration, reduced vascular refilling, or impaired cardiovascular response 4, 5

• Chronic hypotension (systolic BP <100 mmHg interdialytically) affects 5-10% of hemodialysis patients and is characterized by reduced total peripheral vascular resistance despite preserved cardiac index 6

• Hypertension during dialysis can result from volume overload, inappropriate sodium modeling, or activation of the renin-angiotensin system 4, 5

Electrolyte and Metabolic Complications

Potassium Disorders

• Rapid potassium removal causes cardiac arrhythmias and requires careful dialysate potassium concentration selection 5

• Hyperkalemia between sessions poses life-threatening risk and may require emergency dialysis 5

Sodium and Fluid Balance

• Sodium concentration in dialysate directly affects interdialytic weight gain and intradialytic hemodynamic stability 5

• Fluid overload unresponsive to ultrafiltration may require more frequent dialysis sessions 2, 7

Acid-Base Disorders

• Metabolic acidosis can be severe and requires appropriate buffer selection (bicarbonate vs. acetate) in dialysate 5

Calcium and Phosphorus

• Calcium concentration affects hemodynamic stability, mineral bone disease, and cardiac arrhythmias 5

• Phosphorus accumulation contributes to cardiovascular calcification and mortality 4

Cardiovascular Complications

The cardiovascular risk in dialysis patients is 10-20 times higher than in the general population. 8

• Left ventricular hypertrophy affects approximately 75% of patients by dialysis initiation, having developed progressively during earlier stages of chronic kidney disease 1

• Peripheral vascular disease in dialysis patients should not automatically result in amputation—revascularization (surgical or angioplasty with stent) is the preferred treatment in selected patients who are ambulatory or use the affected extremity for weight bearing 1

• Primary amputation is indicated only for extensive tissue necrosis in non-weight-bearing limbs, preoperative infection, or chronically bedridden patients 1

Uremic Symptom Burden

Regular assessment of uremic symptoms using validated tools is necessary, as symptoms are often underreported and under-recognized by providers. 1, 2

Common Uremic Symptoms

• Seizures, protein-energy wasting, serositis, hiccups, platelet dysfunction, and somnolence are critical uremic manifestations requiring recognition 2

• Bone pain affects many hemodialysis patients, yet only half receive analgesia 1

• Sleep disturbance is common, but less than a quarter receive appropriate treatment 1

Management Approach

• Clinicians must assess symptoms most important to individual patients and prioritize based on patient perceptions of impact on their ability to live the life they want 1

• Extended or more frequent dialysis sessions should be considered for patients with persistent uremic symptoms 2

• Acknowledgment of symptoms and provision of coping strategies is important, even when symptoms cannot be completely relieved 2

• The nephrology multidisciplinary team should take the lead in symptom management with holistic care as the goal 1

Systematic Surveillance and Prevention

Monitoring Protocol

• Regular physical examination of vascular access at every dialysis session to detect early dysfunction 1, 2

• Periodic surveillance using noninvasive methods to assess access blood flow rate (Qa), recirculation, and venous pressure 1

• Diagnostic imaging (Doppler ultrasound or fistulography) upon detection or suspicion of access abnormality 1

Quality Improvement

• Regular interdisciplinary team meetings to address all aspects of dialysis care 2

• Systematic assessment and documentation of complications during routine visits 2

• Development of individualized care plans addressing each element of potential complications 2

• Patient education and engagement in self-management is essential for early complication recognition 2

Critical Pitfalls to Avoid

• Do not ignore subtle changes in access examination findings—90% of abnormal physical examinations correlate with clinically significant imaging findings 1

• Do not delay intervention for hemodynamically significant stenosis—untreated stenosis leads to thrombosis and access loss 1

• Do not assume symptoms are unrelated to dialysis—there is high discordance between symptoms experienced by patients and those identified by providers 1

• Do not use hemoglobin A1C as the sole marker of glycemic control in dialysis patients—it may underrepresent true glycemic status due to anemia and shortened red cell lifespan 1

• Do not overlook hypoglycemia risk in diabetic dialysis patients—prolonged drug half-life and increased insulin duration increase risk 1