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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 208-214
Spectrum of complications in chronic kidney disease patients undergoing maintenance hemodialysis: An experience of a tertiary care center in Nepal

1 Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Medical Student, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
3 Department of Pathology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

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Date of Submission09-Dec-2017
Date of Acceptance08-Jan-2018
Date of Web Publication26-Feb-2019


The burden of chronic kidney disease (CKD) is increasing worldwide. Renal replacement therapy is the lifesaving treatment modality in end-stage renal disease. Among various renal replacement modalities, hemodialysis (HD) is widely preferred one. Intradialytic complications are common and mostly inevitable. This study was conducted to determine pattern of intradialytic complications and its associated factors. This is a cross-sectional study conducted for six months duration among all CKD patients who were undergoing maintenance HD in B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Of 228 patients, most were male 141 (61.8%) with median age 50 years (22–77). In this study, diabetic nephropathy (38.2%) was the most common etiology of CKD. Among 228 patients, complications were noted in 133 (58.3%) patients. Common complications were chills and rigor (44.3%), backache (30.7%), and hypotension (27.2%) in the study patients. Intradialytic complications were significantly associated with increasing age (P <0.001) and irregular HD (P <0.001). The common complications among CKD patient undergoing maintenance HD were chills, backache, and hypotension. Increasing age and irregular HD were significantly associated with intradialytic complications.

How to cite this article:
Bartaula B, Subedi M, Kumar MM, Shrestha M, Bichha N, Mudbhari B. Spectrum of complications in chronic kidney disease patients undergoing maintenance hemodialysis: An experience of a tertiary care center in Nepal. Saudi J Kidney Dis Transpl 2019;30:208-14

How to cite this URL:
Bartaula B, Subedi M, Kumar MM, Shrestha M, Bichha N, Mudbhari B. Spectrum of complications in chronic kidney disease patients undergoing maintenance hemodialysis: An experience of a tertiary care center in Nepal. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2021 Oct 19];30:208-14. Available from: https://www.sjkdt.org/text.asp?2019/30/1/208/252912

   Introduction Top

Chronic kidney disease (CKD) is emerging chronic health burden globally.[1] Increased incidence is because of increasing diabetes[2] and hypertension.[3],[4] Study from India by Modi and Jha regarding the incidence of end-stage renal disease (ESRD) in India concluded the adjusted incidence of ESRD is 229 per million[5] and >100,000 new patients enter renal replacement therapy annually,[6] A community screening for CKD, hypertension, diabetes and their management in Dharan, Nepal, a study by Sharma et al observed the prevalence of CKD in urban Nepal is around 10.6%.[7]

Scribner et al was pioneer in hemodialysis (HD) for oligoanuric acute kidney injury (AKI)[8] and such service was first started in Nepal at Bir Hospital in 1987.[9] Standard HD is considered if three times a week for 4 h every time.[10] Adequate HD will relieve patients from various adverse events of uremia such as nausea and vomiting, pruritis, restless leg, and various metabolic complications though may rarely potentiate or even worsen some uremic complications.[11]

HD is one of the relatively safe procedures with an estimated one death in 75,000 treatments as a result of technical error.[12] Various complications such as hypotension, muscle cramps, chest pain, hypoglycemia, and chills, occurs during dialysis and some like ascites increase even after dialysis.[11] One study by Prabhakar et al also showed complications are common during HD despite relatively safe procedure.[12] Intra-dialytic complications were associated with increasing age, diabetes, various comorbid conditions, and frequency of dialysis.[12]

HD is one of the commonly used treatment modalities for ESRD in Nepal[13] as well. Despite being relatively safe but is not completely free of complications. Increasing complications is probably due to irregular dialysis, delay in seeking treatment for CKD, reuse of dialyzer in the study populations. There are very few studies from Nepal regarding complications during dialysis. One such study is by Agrawal et al[14] regarding acute intradialytic complications in CKD patients but had very small sample size which may not be able to reflect the real scenario. Hence, the necessity of more number of studies regarding HD and its complications in larger population was felt. This study aimed to determine the spectrum of complications and its associated factors at B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal.

   Materials and Methods Top

This was a cross-sectional study in 228 patients with ESRD under maintenance HD in the Department of Internal Medicine dialysis unit of BPKIHS of six months. All patients with age 15 years and above and with CKD under maintenance HD were included for the study.

Patients with the diagnosis of AKI under HD and peritoneal dialysis were not enrolled in this study.


All patients coming for maintenance HD were observed during the study. History was taken regarding the cause of CKD, the frequency of HD, complications noted earlier, past medical history and family history. General survey of patient was done before the start of HD and any abnormal findings were recorded in pro forma. Any significant adverse event during HD was also noted and treatment if required is provided by the attending physician as per standard protocol.

Dialysis settings

HD was done in dialysis unit of BPKIHS with synthetic hemodialyzer Elisio-15M model with dialysate flow being 500 mL/min and blood flow of 250–300 mL/min. Dialyzer is being reused for certain periods and only discarded after one use if the patient is a case of sepsis. The dialysate is at normal room temperature. HD was carried through AV fistula, jugular catheter or femoral catheter as per availability.

Data collection

All the data regarding the sociodemographic profile of the patient, vitals, etiological diagnosis, duration of dialysis, frequency, site of dialysis and the complications during intradialytic sessions was taken in performed pro forma of the patient after getting informed consent.

   Statistical Analysis Top

The collected data were entered in MS Excel and converted into Statistical Package for Social Sciences version 20 (IBM Corp. Armonk, NY, USA) for statistical analysis. Univariate analysis was performed by calculating the mean, median, and standard deviation. Numerical variables were expressed in mean, percentage and standard deviation. Bivariate analysis was carried out with the help of Chi-square and t-test to access the relationship between independent and dependent variables at the level of significance 0.05.

Ethical clearance for the study was obtained from the Institutional Review Committee of BPKIHS with IRC no: 32/2016

   Results Top

In our study, out of 228 patients, 141 (61.8%) were male. The median age of the patient was 50 years (22–77 years). [Table 1] shows the demographic profile of patients where 43.9% of patients were of age group 41–60 years. Similarly, 38.2% of patients had diabetic nephropathy and 30.6% of patients had hypertensive nephropathy as shown in [Table 1].
Table 1: Baseline characteristics of all patients with CKD undergoing hemodialysis.

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Complications were present in 133 (58.3%) patients as shown in [Table 1]. [Figure 1] shows the pattern of different intradialytic complications with 44.3% of patients developing chills and rigor which was predominant complications.
Figure 1: Different complications during hemodialysis.

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Only 78 (34.2%) patients are getting twice weekly dialysis rest 150 patients were not getting adequate dialysis as shown in [Table 2].
Table 2: Frequency of hemodialysis.

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[Table 3] shows increasing age was significantly associated with more intradialytic complications as 82.8% (P <0.001) patients of age group more than 60 years had documented complications. Furthermore, study found that 83.3% (P <0.001) receiving irregular dialysis had complications as shown in [Table 3].
Table 3: Association of complications with different factor in hemodialysis.

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   Discussion Top

There were 228 patients of CKD undergoing HD in BPKIHS during the study period. The study demonstrated complications occurred frequently in HD patients. Complications such as chills, hypotension, and backache were frequent and associated with irregular pattern of dialysis and increasing age significantly.

With the gradual improvement in the technical skills as well as educational level there is decline in serious complications during HD; however, less fatal complications are prevalent in good numbers which can further be minimized with vigilance and timely intervention.

More number of patients was of age group 41–60 with median age being 50 years which is similar to one of the studies from Nepal by Chhetri et al[13] where the median age of patients undergoing HD was around 46 years. Similar findings were seen in study from India[15],[16] as well. The increasing incidence of disease in elderly population is probably due to the lack of timely screening of chronic diseases such as diabetes and hypertension. This also reflects the poor socioeconomic state of patients of developing world, which abide them for earlier diagnosis and treatment of these preventable disease and later land up with chronic diseases.

Male patients were predominant 61.8 % which is similar to studies from Nepal[13],[17] showing male dominance in treatment seeking behavior in our part of the world.

Diabetic nephropathy was found to be the most common cause of CKD in patients undergoing HD. This finding was similar to study by Hossain et al where survey in 10 Asian countries regarding ESRD showed nine out of 10 countries were due to diabetic nephropathy.[18] The increasing number of diabetics in developing countries may be the reason for increasing diabetic nephropathy. Moreover, probably the shift of disease paradigm in developing world also toward noncommunicable disease is due to increase stress, sedentary lifestyle, dietary habits, etc.

The study showed only 34.2% of patients were getting twice weekly dialysis. This result was better than earlier study from Nepal by Chhetri et al[13] where only 20% of the patients continued on twice weekly HD. The increase in number from earlier study is due to increase in dialysis facilities in Nepal, policy of Government of Nepal to make HD service free for all CKD patients and improved transportation. However, still the number getting treatment is too low showing the need of more HD services for proper and adequate care.

Chills and rigor was the most common complication in our study with 44.3% of the population. Dialyzer related issues such as reuse of dialyzer, dialyzer reactions were probably the cause of chills and rigor. Our study patients were also getting frequent blood transfusions which may be the other source of chills and rigor. Similar episode of chills and rigor was seen in study by Prabhakar et al.[12] This can probably be minimized by single use of dialyzer or proper application of disinfectant if is reused. Furthermore demand the need of use of other treatment modalities to correct anemia and avoiding frequent blood transfusions.

Backache was the second most common complication in our study which was nonspecific type and was due to long hours of immobilization, and probably dialyzer reactions. This can be minimized by frequent changing in postures during dialysis, providing comfortable beddings and use new and biocompatible dialyzer as possible.

Hypotension was another frequent and troublesome event noticed in 27.20% of population. Use of anti-hypertensive before dialysis, feeding during dialysis, and overzealous removal of ultra-filtrate during dialysis was the possible factors. This finding shows the need of proper predialytic checkup of patients regarding ultrafiltrate removal and deciding about their medications before HD.

The study also showed 13.60% of patients having muscle cramps during the period of HD which was probably due to excessive fluid removal or dyselectrolytemia. Nausea and vomiting was seen in 11.8% population which was probably due to hypotension.

Likewise, chest pain was present in 10.10% of population probably due to dialyzer reaction, increase flow in dialysis or underlying cardiac diseases.

Only few cases were noted to have hypoglycemia during HD probably blood sugar is not measured as routine procedure during dialysis. During the study period two patient developed intracranial hemorrhage which may be due to heparin-related complications or intradialytic hypertension. This emphasized the proper monitoring of blood pressure during dialysis and conscious in the use of heparin.

There was also strong association between the frequency of HD and intradialytic complications. Those getting twice weekly had lesser complications than getting weekly and irregular dialysis. One study in complications during HD by Ranganathan[19] also emphasized of not improvement in survival rates in patients getting inadequate dialysis. Inadequate clearance of toxins, no physiological clearance by infrequent dialysis may be the cause of complications due to infrequent dialysis.

This study showed strong association of complications with increasing age. Increasing complications noted may be due to the presence of various comorbidities such as diabetes and hypertension. Proper control of these risk factors prior and during dialysis may lead to the decrease episode of intradialytic complications.

   Limitation of the Study Top

There were no adequate data regarding the management of complications. No comparison between patients developing complications with normal one which may be helpful to know the morbidity and mortality in patients developing intradialytic complications.

   Conclusions Top

Despite being the safe modality HD is associated with various complications some may be life threatening. Furthermore, the dynamics of complications are frequently changing with its associated factors. One should be more vigilant to identify the complications.

   Acknowledgement Top

I would like to take opportunity to acknowledge all the authors for their constant dedication and hard work to make this project happen. The hard work and dedications of three students author Mr. Navneet, Mr. Mayank and Ms. Monika during the time of data collection, data recording, helping in protocol building worth praising personally from my side also. Other two authors Dr. Manish and Dr. Bandana were directly involved from the time of protocol building till the day of manuscript submission which made our job look easier. Finally I will again like to thank and congratulate all authors for the success of our devotion and dedication.

Conflict of interest:

None declared.

   References Top

Ruggenenti P, Schieppati A, Remuzzi G. Progression, remission, regression of chronic renal diseases. Lancet 2001;357:1601-8.  Back to cited text no. 1
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 2
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.  Back to cited text no. 3
Anand MP. Prevalence of hypertension amongst Mumbai executives. J Assoc Physicians India 2000;48:1200-1.  Back to cited text no. 4
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 5
Kher V. End-stage renal disease in developing countries. Kidney Int 2002;62:350-62.  Back to cited text no. 6
Sharma SK, Karki P, Baral N, et al. A community screening for chronic kidney disease, hypertension, diabetes and their management in Dharan, Nepal. World Congress of Nephrology, Rio de Janeiro, Brazil; 2007. p. 415.  Back to cited text no. 7
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.  Back to cited text no. 8
Chhetri PK, Satyal PR, Kafle R, Khakurel S, Pradhan BR. Experience of hemodialysis in Bir hospital. Nepal Med Coll J 1999;1:99-101.  Back to cited text no. 9
Susantitaphong P, Koulouridis I, Balk EM, Madias NE, Jaber BL. Effect of frequent or extended hemodialysis on cardiovascular parameters: A meta-analysis. Am J Kidney Dis 2012;59:689-99.  Back to cited text no. 10
Himmelfarb J. Hemodialysis complications. Am J Kidney Dis 2005;45:1122-31.  Back to cited text no. 11
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.  Back to cited text no. 12
Chhetri PK, Manandhar DN, Bhattarai SP, Pahari LR, Shrestha R. Chronic kidney disease 5 on hemodialysis in Nepal medical college teaching hospital. Nepal Med Coll J 2008;10:8-10.  Back to cited text no. 13
Agrawal RK, Khakurel S, Hada R, Shrestha D, Baral A. Acute intradialytic complications in end stage renal disease on maintenance hemodialysis. JNMA J Nepal Med Assoc 2012;52:118-21.  Back to cited text no. 14
Mittal S, Kher V, Gulati S, Agarwal LK, Arora P. Chronic renal failure in India. Ren Fail 1997;19:763-70.  Back to cited text no. 15
Sakhuja V, Jha V, Ghosh AK, Ahmed S, Saha TK. Chronic renal failure in India. Nephrol Dial Transplant 1994;9:871-2.  Back to cited text no. 16
Mishra D, Koirala P. Status of chronic kidney disease patients registered in National Kidney Center, Banasthali, Kathmandu. J Manmohan Mem Inst Health Sci 2015;1:19–3.  Back to cited text no. 17
Hossain MP, Goyder EC, Rigby JE, El Nahas M. CKD and poverty: A growing global challenge. Am J Kidney Dis 2009;53:166-74.  Back to cited text no. 18
Ranganathan D, John GT. Nocturnal hemodialysis. Indian J Nephrol 2012;22:323-32.  Back to cited text no. 19
[PUBMED]  [Full text]  

Correspondence Address:
Bijay Bartaula
Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan
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DOI: 10.4103/1319-2442.252912

PMID: 30804283

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  [Table 1], [Table 2], [Table 3]


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