Common complications during hemodialysis include hypotension, muscle cramps, nausea/vomiting, and headaches. Hypotension occurs in 15-50% of sessions and can be caused by rapid fluid removal, autonomic dysfunction, or cardiac issues. Muscle cramps affect up to 90% of patients and may be caused by electrolyte imbalances. Nausea and headaches are often associated with hypotension. Other potential issues include chest pain, air embolism, and hemolysis. Preventing complications focuses on gradual fluid removal and treatment of underlying causes.

2. Spotlight on complicationSpotlight on complication
during hemodialysisduring hemodialysis

3. Common ComplicationsCommon Complications
Serious complicationsSerious complications
Mechanical ComplicationsMechanical Complications

4. Common ComplicationsCommon Complications

5. 1-Hypotension1-Hypotension
2-Muscle Cramps2-Muscle Cramps
3-Nausea and Vomiting3-Nausea and Vomiting
4-Headache4-Headache
5-Chest Pain, Back Pain5-Chest Pain, Back Pain
6-Itching6-Itching
7-Fever and chills7-Fever and chills

6. HypotensionHypotension
 15-50% of dialysis sessions and15-50% of dialysis sessions and
can be episodic or, less commonly,can be episodic or, less commonly,
persistentpersistent
causes:causes:

7. @-Treatment-specific causes@-Treatment-specific causes
1-Rapid fluid removal (high UF rate)1-Rapid fluid removal (high UF rate)
2-Antihypertensive agent use2-Antihypertensive agent use
3-Rapid reduction in plasma osmolality3-Rapid reduction in plasma osmolality
(leading to water movement from the(leading to water movement from the
vascular into interstitial compartment)vascular into interstitial compartment)
4-Warm dialysate4-Warm dialysate
5-Low sodium dialysate5-Low sodium dialysate
6-Low dialysate osmolarity6-Low dialysate osmolarity
7-Use of acetate as buffer (a vasodilator)7-Use of acetate as buffer (a vasodilator)

8. @-Patient-specific causes@-Patient-specific causes
1-Diabetes1-Diabetes
2-Autonomic neuropathy2-Autonomic neuropathy
3-Reduced cardiac reserve (especially LVH3-Reduced cardiac reserve (especially LVH
and diastolic dysfunction)and diastolic dysfunction)
4-Arrhythmias4-Arrhythmias
5-Poor nutritional state5-Poor nutritional state
6-High weight gain6-High weight gain
7-Ingestion of food during dialysis (increased7-Ingestion of food during dialysis (increased
splanchnic venous pooling)splanchnic venous pooling)
8-Antihypertensive agents impairing cardiac8-Antihypertensive agents impairing cardiac
stability and reflexesstability and reflexes

9. @-Less common causes of@-Less common causes of
hypotensionhypotension
1-Pericardial effusion or tamponade.1-Pericardial effusion or tamponade.
2-Reactions to dialysis membranes.2-Reactions to dialysis membranes.
3-Increased dialysate magnesium.3-Increased dialysate magnesium.
4-GI bleeding.4-GI bleeding.
5-Disconnection of blood lines.5-Disconnection of blood lines.
6-MI.6-MI.
7-Haemolysis.7-Haemolysis.
8-Air embolism8-Air embolism

10. Management of hypotensionManagement of hypotension

11. Episodes of hypotension can lead to morbidity, andEpisodes of hypotension can lead to morbidity, and
contribute to cardiovascular mortality.contribute to cardiovascular mortality.
Immediate management requires volumeImmediate management requires volume
resuscitation:resuscitation:
1-place patient head-down;1-place patient head-down;
2-administer 100 ml bolus of normal saline (some2-administer 100 ml bolus of normal saline (some
units use 10 ml of 23% saline, 30 ml 7.5% saline, 50units use 10 ml of 23% saline, 30 ml 7.5% saline, 50
ml 20% mannitol or albumin solutions);ml 20% mannitol or albumin solutions);
3-reduce UF rate to zero;3-reduce UF rate to zero;
if BP does not normalize rapidly, further saline mayif BP does not normalize rapidly, further saline may
be givenbe given..

12. If hypotension occurs repeatedlyIf hypotension occurs repeatedly
review:review:
1-dry weight (too low?)1-dry weight (too low?)
2-use of short-acting antihypertensive2-use of short-acting antihypertensive
3-UF rate;3-UF rate;
4-weight gains between sessions4-weight gains between sessions
5-dialysate sodium (keep above plasma5-dialysate sodium (keep above plasma
sodium);sodium);
6-use bicarbonate not acetate dialysate6-use bicarbonate not acetate dialysate
7-lower dialysate temperature to 34-36 C7-lower dialysate temperature to 34-36 C
8-increase Hb.8-increase Hb.
9-avoid food intake during dialysis.9-avoid food intake during dialysis.

13. Prevention of hypotensionPrevention of hypotension

14. 1-Time on dialysis1-Time on dialysis
(Slower, longer dialysis often cures episodic(Slower, longer dialysis often cures episodic
hypotension)hypotension)
2- Sodium ramping or profiling2- Sodium ramping or profiling
3- Sequential UF and isovolaemic dialysis3- Sequential UF and isovolaemic dialysis
4-Temperature modelling4-Temperature modelling
5-Carnitine5-Carnitine

15. Muscle Cramps

16. Occur in up to 90% of dialysisOccur in up to 90% of dialysis
treatments, mainly towards the end oftreatments, mainly towards the end of
dialysis.dialysis.
A significant cause for early terminationA significant cause for early termination
and underdialysisand underdialysis..

17. Cause not entirely clear, but associatedCause not entirely clear, but associated
withwith
@-Hyponatraemia@-Hyponatraemia
@-Hypotension.@-Hypotension.
@-Hypovolaemia.@-Hypovolaemia.
@-Hypoxia.@-Hypoxia.
@-carnitine deficiency.@-carnitine deficiency.
Cramps are increased in patients usingCramps are increased in patients using
low sodium dialysate and requiringlow sodium dialysate and requiring
increased UF.increased UF.

18. ManagementManagement
@-Minimize interdialytic weight gain and need for@-Minimize interdialytic weight gain and need for
excessive UF.excessive UF.
@-prevent dialysis hypotension.@-prevent dialysis hypotension.
@-higher sodium dialysate, or sodium profiling.@-higher sodium dialysate, or sodium profiling.
@-Carnitine supplementation@-Carnitine supplementation

19. @-Acutely, intravenous saline (normal@-Acutely, intravenous saline (normal
or hypertonic) and intravenous 50%or hypertonic) and intravenous 50%
dextrose are very effective (but salinedextrose are very effective (but saline
will contribute to hypertension andwill contribute to hypertension and
volume overload).volume overload).
@-Local massage offers some relief.@-Local massage offers some relief.

20. Nausea, vomiting, and headacheNausea, vomiting, and headache

21. CausesCauses
@-Common, and usually associated@-Common, and usually associated
with hypotension.with hypotension.
@-May be a minor manifestation of@-May be a minor manifestation of
disequilibrium syndrome due to excessdisequilibrium syndrome due to excess
urea removalurea removal
@-Patients with persistent marked@-Patients with persistent marked
uraemia.uraemia.
@-Rarely precipitated by caffeine or@-Rarely precipitated by caffeine or
alcohol withdrawal during dialysisalcohol withdrawal during dialysis..

22. ManagementManagement
@-Treat and prevent hypotension.@-Treat and prevent hypotension.
@-Antiemetics and paracetamol may help if@-Antiemetics and paracetamol may help if
not precipitated by hypotension.not precipitated by hypotension.
@-Reduction of blood flow rate (by 25-30%)@-Reduction of blood flow rate (by 25-30%)
during first hour of dialysis sometimes usefulduring first hour of dialysis sometimes useful
..
@-Use bicarbonate rather than acetate@-Use bicarbonate rather than acetate
dialysis.dialysis.

23. Chest painChest pain
Commonly caused by angina, but alsoCommonly caused by angina, but also
by hypotension, dialysis disequilibriumby hypotension, dialysis disequilibrium
syndrome, haemolysis, and airsyndrome, haemolysis, and air
embolism. Recurrent angina duringembolism. Recurrent angina during
dialysis should be investigateddialysis should be investigated
cardiologically, and can be treated withcardiologically, and can be treated with
B-blockers or nitrates .B-blockers or nitrates .
Both agents may cause hypotension.Both agents may cause hypotension.

24. Air embolismAir embolism
Rare, as air detectors will clamp venousRare, as air detectors will clamp venous
blood lines if air is detected in the returnblood lines if air is detected in the return
circuitcircuit
Introduction of 1 ml/kg air may be fatalIntroduction of 1 ml/kg air may be fatal..

25. In sitting patients air tends to move upwardsIn sitting patients air tends to move upwards
into cerebral venous circulation and causeinto cerebral venous circulation and cause
fitting and coma.fitting and coma.
In recumbent patients it causes chest pain,In recumbent patients it causes chest pain,
dyspnoea, chest tightness and cough, anddyspnoea, chest tightness and cough, and
may pass through the pulmonary vascularmay pass through the pulmonary vascular
bed and embolize into arterioles causingbed and embolize into arterioles causing
acute neurological signs.acute neurological signs.
Foam is usually seen in the venous bloodFoam is usually seen in the venous blood
line.line.

26. ManagementManagement
@-@-Clamp venous line and stop blood pump.Clamp venous line and stop blood pump.
@-Place patient in left lateral position, with@-Place patient in left lateral position, with
head and chest down.head and chest down.
@-Administer 100% O@-Administer 100% O22 (enhances nitrogen(enhances nitrogen
diffusion out of air bubbles), anddiffusion out of air bubbles), and
cardiopulmonary support as necessary.cardiopulmonary support as necessary.
@-Rarely, percutaneous aspiration of air@-Rarely, percutaneous aspiration of air
from the ventricle necessaryfrom the ventricle necessary..

27. HaemolysisHaemolysis
Severe haemolysis is rare, but can causeSevere haemolysis is rare, but can cause
chest pain, abdominal or back pain, chestchest pain, abdominal or back pain, chest
tightness, headache, nausea, and malaisetightness, headache, nausea, and malaise..

28. Life threatening hyperkalaemia can occur ifLife threatening hyperkalaemia can occur if
unrecognized.unrecognized.
Should especially be considered if severalShould especially be considered if several
patients complain of similar symptomspatients complain of similar symptoms
simultaneously.simultaneously.
Venous blood may develop a darkerVenous blood may develop a darker
appearance, and plasma will appear pink inappearance, and plasma will appear pink in
clotted or spun blood samples.clotted or spun blood samples.
Hb fallsHb falls..

29. CausesCauses ::
@-overheating of dialysate;@-overheating of dialysate;
@-contamination with bleach, formaldehyde,@-contamination with bleach, formaldehyde,
or peroxide from water purification oror peroxide from water purification or
reprocessing;reprocessing;
@-chloramine, nitrates, or copper from@-chloramine, nitrates, or copper from
water supply;water supply;
@-hypotonic dialysate;@-hypotonic dialysate;
@-kinks in blood tubing;@-kinks in blood tubing;
@-malfunctioning blood pump.@-malfunctioning blood pump.

30. ManagementManagement
Stop blood pump immediately andStop blood pump immediately and
clamp lines.clamp lines.
Risk of severe hyperkalaemia.Risk of severe hyperkalaemia.
Check potassium and Hb.Check potassium and Hb.
Haemolysis may continue for severalHaemolysis may continue for several
hours after removal of precipitant.hours after removal of precipitant.
Seek cause urgently, as multipleSeek cause urgently, as multiple
patients may be affected if it is due topatients may be affected if it is due to
water or a central dialysate problemwater or a central dialysate problem..

31. ThanksThanks
Dr MDr M

32. Heamodialysis unit
KFH