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Haemodialysis complications
This document discusses renal failure and its complications. It covers acute complications of renal failure including cardiovascular, neuromuscular, hematological, and technical issues during dialysis. Chronic complications include cardiovascular disease and infections. Common presentations to the emergency department for patients with renal failure include infections, shortness of breath, vascular access issues, chest pain, and gastrointestinal complaints. Several case examples are provided to discuss management of specific complications like hyperkalemia, pulmonary edema, cardiac issues, bleeding, and infections.
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Haemodialysis complications
- 1.
- 2. Renal failure Whatcomes to mind?
- 3. Renal Failure Innocentbystanders – mostly T2DM/HTN/Obesity eGFR <60 = >50% loss Uraemic symptoms PD vs HD vs Conservative care Haemodialysis in theory Intermittent haemodialysis
- 4. Complications What aresome complications?
- 5. Acute complications Cardiovascularcomplications Intradialytic hypotension Intradialytic hypertension Cardiac arrhythmias Sudden Death Angina Neuromuscular complications Muscle cramps Dialysis disequilibrium Seizures Headache
- 6. Acute complications Haematologicalcomplications Complement activation and neutropaenia Heparin induced thrombocytopaenia Haemolysis Haemorrhage Technical malfunctions Air embolism Hyponatraemia/ hypernatraemia / acidosis / alkalosis Temperature Clotting Access Malfunctions Steal Syndrome Reactions Anaphylaxis / Anaphylactoid reactions Priapism
- 7. Chronic complications Cardiovascular Left ventricular hypertrophy Bacterial infections Psychosocial complications Delerium Depression Dementia Nutritional Protein energy wasting
- 8. Presentations to ED Approximately(355 visits by 143 patients): 20% infection 20% SOB 15% vascular access 15% chest pain / arrythmia 15% GI complaints (other) 60% admission rates Average LOS 8 days
- 9. Mr RF, 30MElectrician Recent start on haemodialysis Comes in with shortness of breath VBG – K+ 7.9 What do you do?
- 10. Hyperkalaemia Haemolysis isn’tusually the case Treatment in ED? Gluconate (repeat doses) Care with insulin Twice the care with sodium bicarbonate Care with resonium (onset?) Bowel prep – if youre particularly frustrated Other electrolyte abnormalities ( Ca / Mg / Phos / Na) – not common cause of acute presentation, usually another cause (medications / sepsis)
- 11. Cardiac complications T/FESRD patients carry the same cardiovascular risk as general population. T/F Troponins are commonly significantly elevated in patients on regular dialysis and cannot be trusted as cardiac marker.
- 12. What’s normal? General populationvs ESRF CAD: 12% vs 40% LVH: 20% vs 75% CHF: 5% vs 40%
- 13. Pulmonary Oedema Misseddialysis Thirst (800mL with LVH) Cardio renal syndrome MI 50% of deaths in patients with dialysis 50% mortality in 5 years
- 14. Mr KC 60Mretired accountant It’s a Sunday. Your friends are at the beach. Vasculopath 6 admissions for APO recently, including 2 to ICU, and another 2 with hypertensive crisis (SBP>220) Attended dialysis on Friday, 2L off. Complains of severe SOBAR, speaking in phrases What do you do? What we did….
- 15. Pulmonary oedema –Rx Frusemide (big) GTN infusion NIV HD Phlebotomy
- 16. Mr RF, 68M History of renal amyloidosis. Presented with SOBOE 3/7 ago, thought to be fluid overload, treated with frusemide Now presents again SOBAR. What’s the approach? Peri-arrest….
- 17. Pericarditis / tamponade Everyone has uraemic pericarditis Complicated by anti-platelet and anticoagulant use Poor cardiac reserve What had happened with Mr. RF (warfarin)
- 18. Mr. NM, 65M Nice guy, community HD for ESRF T2DM, stable Dizzy post dialysis What will be your approach? What had happened….
- 19. Anaemia Diagnosis ofexclusion, especially in HD ( eGFR <30 ) ESA, aim for ~100 (trials) Bleed during haemodialysis Malignancies / plasma cell dyscrasias Platelet dysfunction uraemic toxins Oesophagitis, gastristis, angiodysplasia, anticoagulation during HD (~5000 units heparin)
- 20. Treatment of anaemia dDAVP (0.2 micrograms/kg, 15 min) Cryoprecipitate Withdrawal of medications (e.g. allopurinol) Transfusion on dialysis Consideration of future transplant and PRAs
- 21. Mrs PC, 78F, retired nurse OCD traits, looks after husband with lung cancer at home. Sudden onset left knee pain 1/12 ago – managed with OTC analgesics Now presents with right ankle pain, unable to weight bear What would your approach be? What had happened….
- 22. CKD Mineral BoneDisorders Bones ?fracture ?infection Low threshold for CT – microfractures Bony aches and pains Hip and lumbar fractures What’s the PTH – turnover Types Osteitis fibrosa cystica (lytic lesion, painful) Osteomalacia Adynamic bone disease (common, ?calcium treatment) Metastatic calcification (calciphylaxis / vascular – CAD)
- 23. Mr ST, 60M,casino addict Vasculopath, 130kg, with femoral Hickman line “I woke up in a pool of blood.” What’s your approach? What had happened…
- 24. Hickman line complications Cuff exposed “it fell out by itself” Infection – treatment (vanc/gent) Blocked line (tPA lock) Broken clamp Hickman removals (peripheral ED –useful skill)
- 25. Hickman bleeds Hopeits not a subclavian line…. Pressure, gauze Xylocaine adrenaline Red-top tubes Head-up Sand-bag Box-suture Underlying cause
- 26.
- 27. Fistula complications Types– RCF, BCF, Femoral, (PU/PTFE graft) <picture> Examination – infection, thrill, bruit, central stenosis, aneurysm, thrombosis, bleeding Investigation: USS – flows, thrombus, cellulitis Swabs, Hickman (dialysis nurses or heparin lock) and peripheral cultures
- 28. Bleeding fistula Carefulpressure Torniquet Box suture Surgeons
- 29. Blocked fistula UrgentUSS for flow Clexane (0.8mg/kg – MDRD) Interventional radiology / nephrology Surgeons (GS 5 or, vascular)
- 30. Bacterial infections Tayloret al 2004, RR of bloodstream infections AVF AVG 1.47 Tunnelled 8.49 Non-Tunnelled 9.87 Weijmer et al 2004, site vs CRBSI Femoral 7.6 per 1000 catheter days Jugular 5.6 Subclavian 0.7 Bacteraemia AVF 0.04 per 1000 patient days, AVG 0.55 per 1000 patient days Lafrance et al 2008 up to 6.5 for CRBSI S. aureus (40%), seeding, mortality, MRSA
- 31.
- 32. 49M, Fijian Diabeticwith industrial adiposity. Home haemodialysis. Recent return from family holiday for 7 days. Presents to Kattaning ED with confusion What is your approach? What had happened…
- 33. Dialysis Dysequilibrium Pathophysiology Urea is slow…. Creatinine is a preservative…. Note epilepsy and dialysing drugs out Urgent CTB Slow flow dialysis, supportive care, maybe mannitol
- 34. The surprises fromG65 Apologies Hypotension Excessive fluid removal Sepsis Cardiac tamponage (heparin on HD) GI haemorrhage (and only the finger knows) MI / arrythmia (30% ventricular, ~50% AF)
- 35. Steal syndrome Calciphylaxis Pain, pallor, cold/weak extremity Digital necrosis Myocardial ischaemia
- 36. Contrast in haemodialysis No proof to schedule dialysis Takes up to 3 sessions of dialysis to remove contrast, depending on type Some evidence that questions the phenomenon of contrast induced nephropathy in the first place (CJASN 2016) No reproducible protection in non-HD CKD patients who had dialysis post contrast administration (Kid Int 20006) + risk of dialysis
- 37. Pain management inHD Morphine – dirty, dialysed, use half of usual Codeine – not dialysed Fentanyl – not dialysed Buprenorphine – short acting, dialysed out Hydromorphone – who knows? This and other medications on – renal drug database
- 38. Things to know Months/years on dialysis, cause Access – creation, complications, function Symptoms of infection Last session, duration Weight and volume status, JVP, blood pressure(s) Usual intradialytic weight gains Usual trend of potassium / bicarbonate Residual urine output Cardiac history
Editor's Notes
- #2 https://www.ahcmedia.com/articles/77642-emergencies-in-the-dialysis-patient
- #9 Clin Nephrol. 2002 Jun;57(6):439-43. The emergency department care of hemodialysis patients. Loran MJ1, McErlean M, Eisele G, Raccio-Robak N, Verdile VP. Author information Abstract AIMS: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. MATERIALS AND METHODS: A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. RESULTS: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. CONCLUSION: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.
- #23 DOPPS COSMOS EVOLVE - cinacalcet