| Abstract|| |
Hemodialysis (HD) is one of the important modalities of renal replacement therapy in acute renal failure (ARF) as well as chronic renal failure (CRF). This study was performed to evaluate the various intradialytic complications that occur during HD and their management. This is a retrospective study performed in patients who underwent conventional HD during the period of 1 January 2000 to 31 December 2011 at our center. Clinical details, various complications faced and their management were retrieved from dialysis case sheets. A total of 2325 patients of renal failure (790 ARF and 1535 CRF patients) were assessed for the intradialytic complications of HD. During the study period, there were 12,785 bicarbonate dialyses performed on these patients. In the ARF patients, the common intradialytic complications were: Hypotension, seen in 1296 sessions (30.4%), nausea and vomiting seen in 1125 sessions (26.4%), fever and chills seen in 818 sessions (19.2%), headache seen in 665 sessions (15.6%), cramps seen in 85 sessions (2.0%), chest pain and back pain seen in 82 sessions (1.92%), hypoglycemia seen in 77 sessions (1.8%), first-use syndrome seen in 72 sessions (1.7%) and femoral hematoma seen in 31 sessions (0.73%). In the CRF group, common complications were hypotension in 2230 sessions (26.1%), nausea and vomiting in 1211 sessions (14.2%), fever and chills in 1228 sessions (14.4%), chest pain and back pain in 1108 cases (13.0%), hypertension in 886 sessions (10.4%), headache in 886 sessions (10.4%), cramps in 256 sessions (3.0%), hematoma in 55 sessions (0.64%), intracerebral hemorrhage in three sessions (0.03%) and catheter tip migration in three sessions (0.03%). There is a need for special attention for the diagnosis and management of intradialytic complications of HD because such complications could be managed successfully without the need for termination of the dialysis procedure.
|How to cite this article:|
Prabhakar, Singh RG, Singh S, Rathore SS, Choudhary TA. Spectrum of intradialytic complications during hemodialysis and its management: A single-center experience. Saudi J Kidney Dis Transpl 2015;26:168-72
|How to cite this URL:|
Prabhakar, Singh RG, Singh S, Rathore SS, Choudhary TA. Spectrum of intradialytic complications during hemodialysis and its management: A single-center experience. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Mar 1];26:168-72. Available from: https://www.sjkdt.org/text.asp?2015/26/1/168/148771
| Introduction|| |
Hemodialysis (HD) is a life-saving treatment modality that has only been routinely applied for end-stage renal disease (ESRD) for the past 35 years.  Pioneering physicians Merrill et al successfully supported patients through the oligo-anuric phase of acute kidney injury (AKI).  Teschan introduced HD to the battlefield during the Korean War  . In 1944, Willem Kolff succeeded in inventing extra-corporeal dialysis to support patients of AKI.  The highest prevalence rate for ESRD is found in Taiwan, at 2311 per million population (PMP), followed by Japan and the United States, with a rate of 2126 and 1752 PMP, respectively. 
HD patients are more likely to have cardiovascular disease, cerebro-vascular disease, peripheral vascular disease and chronic obstructive pulmonary disease. HD should be initiated at a level of residual renal function above which the major symptoms of uremia usually supervene. Among the accepted criteria for initiating dialysis in the United States are residual creatinine clearances of 15 mL/min and 10 mL/min for diabetics and nondiabetics, respectively. Clinical practice guidelines suggest that dialysis should be initiated at a creatinine clearance between 9 and 14 mL/ min.  At best, with current HD technology, thrice-weekly sessions of 5 h each will achieve the equivalent urea clearance of approximately 20 mL/min in a 70 kg individual. Once the creatinine clearance falls below 20 mL/min, patients should be periodically questioned regarding symptoms related to nutrition, loss of appetite, nausea or vomiting, especially in the morning, owing to overnight retention of uremic toxins in the gut and unintended weight loss. These are very often the earliest markers of uremia. Asterixis, restless leg syndrome and a reversal of the sleep-wake cycle are early neurologic manifestations of uremia. If alternative explanations for these symptoms and signs cannot be discerned, these are indications for initiating dialysis. HD has evolved into a relatively safe procedure, with an estimated one death in 75,000 treatments as a result of technical error. However, an extensive list of complications is related to this treatment, some of which are potentially life-threatening. In this discussion of the acute complications, it should be noted that the age of the patient, the presence of underlying medical conditions such as diabetes mellitus, coronary artery disease or chronic heart failure and the patient's degree of compliance with a complex medical regimen have a great influence on the frequency and severity of adverse events. In the early days of HD, allergic reactions to dialyzer membranes, sterilizing and reprocessing agents and contaminated dialysate-associated complications were common with HD. The clinical spectrum of HD-associated complications has changed over the decades. Our study highlights the acute intradialytic complications of conventional HD and their management.
| Materials and Methods|| |
This retrospective study involved all cases of HD performed during the period of 1 January 2000 to 31 December 2011, regardless of age, sex, race and cause of renal failure. Clinical details, various complications faced and their management was retrieved from dialysis case sheets. Bicarbonate HD was performed in all these patients. TR-FX (Torray Med Co. Ltd. ARCA Central 21 F, 2-1, Kinshi 1-chome, Sumida-ku, Tokyo 130-0013, Japan) conventional HD machines were used for HD in these patients at dialysate and blood flow rates of 500 and 250-300 mL/min, respectively.
| Results|| |
During the study period, a total of 2325 patients of renal failure [790 acute renal failure (ARF) and 1535 chronic renal failure (CRF) patients] underwent conventional HD. There were 12,785 dialyses performed in these patients. In the ARF patients, common intradialytic complications were hypotension (30.4%), nausea and vomiting (26.4%), fever and chills (19.2%) and headache (15.6%) [Table 1]. In the CRF group, the common complications were hypotension (26.1%), nausea and vomiting (14.2%), fever and chills (14.4%), chest pain and back pain (13.0%), hypertension (10.4%) and headache (10.4%) [Table 1]. Intra-cerebral hemorrhage [Figure 1] and migration of catheter tip [Figure 2] were noted in three patients each. Two patients of intracerebral hemorrhage died during the course of the disease. In all three cases of migration of broken catheter tip, the dislodged portion of the catheter was removed by venotomy and no catastrophic consequences occurred.
|Figure 1: CT scan showing intra-cerebral hemorrhage developed during hemodialysis in a CRF patient.|
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|Figure 2: Broken portion of the femoral venous catheter impacted in the external iliac vein removed by venotomy.|
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|Table 1: Intradialytic complications of HD in ARF (n = 267, 4262 dialyses) and CRF (n = 519, 8523 dialyses) patients.|
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| Discussion|| |
With advances in technology, HD has evolved into a relatively safe procedure; however, a variety of complications are associated with it, some of which may be life threatening. In the literature, hypotension is the most common acute complication (20-50%) of HD, followed by muscle cramps (20%), nausea and vomiting (5-15%), dialysis disequilibrium (10-20%), headache (5%), chest pain (2-5%), itching (5%), fever and chills (< 1%), arrhythmias, hypoglycemia, hemorrhage, blood-membrane interaction like the first use syndrome and acute hemolysis. ,,,,,,,,,,,
In our study, intradialytic hypotension was the most common complication observed in both the groups (ARF 30.4%, CRF 26.1%). It could be due to high ultrafiltration rate, high dialysate temperature, low dialysate sodium, antihypertensive medication, autonomic dysfunction and poor cardiac reserve due to underlying coronary artery disease, but it can be managed successfully by proper assessment of dry weight, sequential ultrafiltration, lowering dialysate temperature and by giving intravenous normal saline and midodrine in refractory cases.
Nausea and vomiting (ARF 26.4%, CRF 14.2%) were the second most common complications, mainly due to intradialytic hypo-tension. Other causes were dialysis disequilibrium syndrome (DDS), high dialysate sodium and calcium concentration and gastroparesis, especially in diabetic patients. It can be managed successfully by avoidance of intradialytic hypotension and administration of a single dose of prokinetic agent before dialysis in recurrent cases.
Fever and chills (ARF 19.2%, CRF 14.2%) were the third most common complications, mainly due to vascular access-related infection and pyrogenic reactions. It can be managed with taking proper antiseptic precautions, proper assessment of access and regular disinfection of HD machine, water treatment plant and distribution system. Prophylactic antibiotics prior to the invasive procedure can prevent this complication. Headache (ARF 15.6%, CRF 10.4%) was also one of the common complications noted, mainly as a manifestation of DDS. Muscle cramps (ARF 2%, CRF 3%) were also common; it was due to excessive ultrafiltration and low dialysate sodium. It can be managed by sequential ultrafiltration and sodium profiling. Chest pain and back pain (ARF 1.92%, CRF 13.0%) were other complications mainly related to dialyzermediated type B reaction, managed by changing the dialyzer. Hypertension (10.4%) was also a common complication noted in the CRF groups, which could be due to the chronicity of the disease associated with pre-existing hypertension, excessive ultrafiltration rate and subsequent volume depletion-induced increased rennin-angiotensin secretion, hypercalcemiainduced increased inotropism and vascular tone, increased sympathetic tone during ultra filtration or anti-hypertensive medication removal during dialysis, which have all been associated with volume-independent hypertension in HD. , First use syndrome and hypoglycemia were the least common complications observed, prevented by proper rinsing of dialyzer and small meals before and during dialysis, respectively. Dialysis-associated complications, like intravenous catheter-associated complications, and sudden death following intra-cerebral hemorrhage are rarely reported.  However, 42% of dialysis deaths were documented as sudden or cardiac in origin, with 22% of deaths related to cardiac arrest and arrhythmias.  We did not come across hemolysis and arrhythmias as complications during HD.
| Conclusion|| |
HD is associated with a vivid number of complications, some of which are life-threatening. However, strict vigilance, proper assessment of patients and good clinical acumen may help in the early detection and timely management without termination of this life-saving treatment modality.
Conflict of interest: None.
| References|| |
Abel JJ, Rowntree LG, Turner BB. On the removal of diffusable substances from the circulating blood by means of dialysis. Transactions of the Association of American Physicians, 1913. Transfus Sci 1990;11:164-5.
Grimsrud L, Cole JJ, Lehman GA, Babb AL, Scribner BH. A central system for the continuous preparation and distribution of hemodialysis fluid. Trans Am Soc Artif Intern Organs 1964;10:107-9.
Teschan PE. Hemodialysis in military casualties. Trans Am Soc Artif Intern Organs. 1955;1:52-4.
Kollf W. First clinical experience with the artificial kidney: A dialyser with a great area. 1944 (classical article). J Am Soc Nephrol 1997;8:1959-65.
U.S. Renal Data System.USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bathesda, MD: National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease; 2010.
National Kidney Foundation: K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. Am J Kidney Dis 2002;39:S1-266.
Schreiber MJ Jr. Clinical case-based approach to understanding intradialytic hypotension. Am J Kidney Dis 2001;38:S37-47.
Jansen PH, Veenhuizen KC, Wesseling AI, de Boo T, Verbeek AL. Randomised controlled trial of hydroquinine in muscle cramps. Lancet 1997;349:528-32.
Sherman RA, Daugridas J, Ing TS. Complications during hemodialysis. In: Daugridas JT, Blake PG, Ing TS, eds. Handbook of Dialysis, 4 th
ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 170-91.
Trinh-Trang-Tan MM, Cartron JP, Bankir L. Molecular basis for the dialysis disequilibrium syndrome: Altered aquaporin and urea transporter expression in the brain. Nephrol Dial Transplant 2005;20:1984-8.
Epstein A, Kay G, Plumb V. Considerations in the diagnosis and treatment of arrhythmias in patients with end-stage renal disease. Semin Dial 1990;2:31-7.
Remuzzi G. Bleeding in renal failure. Lancet 1988;i:1205-8.
Hakim RM, Breillatt J, Lazarus JM, Port FK. Compelment activation and hypersensitivity reactions to dialysis membranes. N Engl J Med 1984;311:878-82.
Sica DA, Harford AM, Zawada ET. Hypercalcemic hypertension in hemodialysis. Clin Nephrol 1984;22:102-4.
Centers for Disease Control and Prevention (CDC). Multistate outbreak of hemolysis in hemodialysis patients-Nebraska and Maryland, 1998. JAMA 1998;280:1299-300.
Zucchelli P, Santoro A, Zucchala A. Genesis and control of hypertension in hemodialysis patients. Semin Nephrol 1988;8:163-8.
Bleyer AJ, Russel GB, Satko GB. Sudden and cardiac deaths rates in hemodialysis patients. Kidney Int 1999;55:1553-9.
Ahmad S, Robertson HT, Golper TA, et al. Multicenter trial of L-carnitine in maintenance hemodialysis patients. II. Clinical and biochemical effects. Kidney Int 1990;38:912-8.
Singh S, Prakash J, Shukla VK, Sharatchandra Singh LK. Intravenous Catheter associated complications. J Assoc Physicians India 2010;58:194-6.
Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
[Figure 1], [Figure 2]