What are the indications to stop a dialysis session?

Indications to Stop a Dialysis Session

Dialysis sessions should be stopped immediately for life-threatening complications including severe intradialytic hypotension with cardiac arrhythmias, dialysis disequilibrium syndrome with seizures or altered mental status, dialyzer clotting that compromises treatment efficacy, equipment malfunction with safety concerns, or severe patient distress that cannot be managed with standard interventions. 1, 2, 3

Acute Medical Emergencies Requiring Immediate Session Termination

Cardiovascular Complications

• Severe symptomatic hypotension that does not respond to standard interventions (reducing ultrafiltration rate, Trendelenburg positioning, fluid bolus) should prompt immediate session termination 1, 2
• Intradialytic hypotension with systolic BP decline >20 mmHg is associated with a 9-fold increased risk of clinically significant arrhythmias (bradycardia ≤40 bpm for ≥6 seconds, asystole ≥3 seconds, ventricular tachycardia ≥130 bpm for ≥30 seconds) 2
• Cardiac arrhythmias detected during monitoring, particularly in the context of hypotension, warrant immediate cessation 2, 4
• Chest pain suggestive of myocardial ischemia, as intradialytic hypovolemia and hypotensive episodes can reduce myocardial perfusion 4

Neurological Emergencies

• Dialysis disequilibrium syndrome presenting with seizures, altered mental status, or obtundation requires immediate termination 3
• This rare but potentially fatal complication occurs more commonly in patients with very high pre-dialysis BUN levels or those new to dialysis 3
• New onset confusion, severe headache, or focal neurological deficits during treatment 3

Equipment and Technical Failures

• Dialyzer clotting that reduces effective dialyzer surface area and compromises treatment efficacy 1, 5
• Dialyzer leaks that could allow blood loss or dialysate contamination 1
• Blood pump failure or malfunction 1
• Dialysate bypass triggered by conductivity or temperature alarms indicating unsafe dialysate composition 1
• Equipment alarms related to air detection or improperly set alarm limits that cannot be immediately corrected 1

Vascular Access Complications

• Severe bleeding from access site that cannot be controlled with standard measures 5
• Suspected access thrombosis with inadequate blood flow 5
• Need for replacement or manipulation of fistula needles due to infiltration or malposition 1
• Signs of access infection requiring immediate intervention 5

Relative Indications for Early Termination

Intractable Symptomatic Complications

• Severe muscle cramps unresponsive to standard interventions (slowing ultrafiltration, hypertonic saline/dextrose administration) 1
• Approximately 70% of premature terminations for medical reasons are due to cramps 1
• Persistent nausea and vomiting making the patient feel severely ill (48% of medical reason terminations) 1
• Severe symptomatic hypotension (15% of medical reason terminations) despite interventions 1

Clinical Context Considerations

While patient request for early termination is documented as a cause of premature discontinuation, this should not be honored without attempting to address the underlying cause of discomfort 1. The NKF-K/DOQI guidelines emphasize that premature discontinuation compromises delivered dialysis dose and should be avoided when possible 1

Palliative Care Context for Dialysis Discontinuation

In patients with severely limited life expectancy, low quality of life, refractory pain, or progressive deterioration from untreatable disease, consensual discontinuation of dialysis may be appropriate 1. This decision should occur through shared decision-making in open, empathetic discussions focusing on symptom burden reduction rather than life prolongation 1

Management Strategies to Avoid Premature Termination

Preventive Interventions

Before stopping a session for symptomatic complications, implement these evidence-based strategies 1:

• Avoid excessive ultrafiltration by reassessing estimated dry weight 1
• Slow the ultrafiltration rate or perform isolated ultrafiltration 1
• Increase dialysate sodium concentration to maintain blood volume 1
• Switch from acetate to bicarbonate-buffered dialysate 1
• Reduce dialysate temperature to improve hemodynamic stability 1
• Administer midodrine pre-dialysis for recurrent hypotension 1
• Correct anemia to recommended ranges per guidelines 1
• Administer supplemental oxygen if indicated 1

Common Pitfall

Do not routinely decrease blood flow and ultrafiltration rate in response to hypotension or cramps without first attempting other interventions, as this compromises the delivered dialysis dose and may result in inadequate treatment 1. The goal is to maintain prescribed treatment parameters while managing symptoms through dialysate composition changes and other supportive measures 1