Hemodialysis complications

Complications of Hemodialysis
 Hemodialysis Procedure Complications
hypotension, hypertension increase the overall
mortality and CVD , cramps, nausea and vomiting,
headache, chest pain, back pain, and fever or chills.

Vascular Access Complications
 Aneurysm and stenosis are associated with
AV fistulas and grafts, and these are
resolved primarily by surgical intervention.
Thrombosis and infection are the most
common vascular access complications with
the highest occurrence found in patients
with a catheter compared with those with
an AV graft or AV fistula.

 Vascular access dysfunction is usually when
blood flow less than 300 mL/min over a period of
days to weeks. Ultrasound, venography, or
computed tomography scans can provide a
definitive diagnosis.

Catheter thrombosis can form either inside (intrinsic) or
outside (extrinsic) the catheter. The occlusion can form
within the lumen at the tip or develop a fibrin sleeve
around the catheter where this fibrin sleeve can serve as
a nidus for infection and ultimately require catheter
removal.

 The risk of sepsis-related death is 100 times
greater in dialysis patients than the general
population.
 Staphylococcus aureus and coagulase-
negative staphylococcus are the source of
infection,gram-negative bacterial and fungal.

 The infection source for long-term catheters
such as a tunneled cuffed catheter is usually the
hub where bacteria can enter the blood leading
to a bloodstream infection.
 HD access with a catheter is associated with
higher rates of bacteremia, osteomyelitis, septic
arthritis, endocarditis, thrombus and death, as
well as increased treatment costs compared with
an AV fistula or AV graft.

Complications of CKD
 HD patients are likely to have at least one
additional co-morbid disease such as
diabetes, hypertension, cardiovascular
disease, or obesity.
 The daily medication burden for HD patients
is one of the highest for any chronic disease
state, on average 11 medications (9 oral and
2 parenteral), which based on the oral
medications alone results in a total burden
of about 19 dosages per day.

Management of Hemodialysis
Complications
Hypotension

Management of hypotension
Non-Pharmacological
 Intradialytic hypotension (IDH) is primarily related to the rate and
amount of fluid removed during typical treatments
 The replacement of acetate with bicarbonate as the dialysate buffer,
the use of volumetric ultrafiltration controllers, as well as
individualized or modeled dialysate sodium concentrations have
helped reduce the incidence of IDH.
 Sodium modeling uses a higher initial dialysate sodium
concentration (145-155 mM) and tapers the sodium concentration
down (135-140 mM) over the dialytic session.

 most treatments are directed toward restoring
or maintaining adequate blood vessel perfusion
in these patients. For example, decreasing the
dialysate temperature to 36.5°C (97.7°F) may
help reduce core body temperature, which can
decrease vasodilation.

Pharmacological
 Oral midodrine (5 mg) given 2 to 3 times daily can increase blood
pressure in HD patients with chronic hypotension on nondialysis
days. It is important to note that the effects of midodrine are
probably best in patients with hypotension related to autonomic
dysfunction. Strongly recommended but its high cost and limited
effeciacy prevent a lot of patient from take it.
 levocarnitine (20 mg/kg IV at the end of each dialysis session)
may reduce hypotensive episodes, particularly with carnitine
deficiency. Intermediate recommendation
 sertraline 50 mg daily titrated to 100 mg daily after 1 week
improved systolic and diastolic blood pressure.
 DDAVP - intra-nasal desmopressin acetate .
 Fludrocortisone for symptomatic HoTN .

Hypertension
 Solution :Changing in antihypertensive
medications or adjustments to the timing of
medication administration.
 Carvedilol initiated at 6.25 mg twice daily and
titrated up to 50 mg twice daily as tolerated
significantly improved intradialytic hypertension
in patients receiving HD.

Notes
 Quinine cause temporary sight and hearing
disturbances, thrombocytopenia, or
gastrointestinal distress.
 vitamin E (400 mg) used synergistically with
vitamin C (250 mg) but vitamin E greater than 400
units per day have been reported to increase
mortality and there is a risk of systemic oxalosis
with the accumulation of a vitamin C metabolite,
oxalate in HD patients.

Vascular access thrombosis
 Oral antiplatelet agents role in the prevention of vascular
access thrombosis has been controversial since efficacy is
not well-established and there is an increased risk of
bleeding.
 Daily aspirin use also is associated with a lower rate of AV
fistula failure and no increase in new GI bleeding.
 The use of warfarin to maintain vascular access patency is
controversial with some trials suggesting an increase in
morbidity and mortality with the use of warfarin, as HD
patient require lower dose than usual.

Fish Oil to prevent thrombosis
 a combination of (fish oil) eicosapentaenoic
acid (EPA) 400 mg and docosahexaenoic
acid (DHA) 200 mg, on AV graft patency for
12 months after graft placement revealed
that the loss of patency was lower in the fish
oil (48%) than the placebo (62%).

 unfractionated heparin (UFH), recombinant tissue
plasminogen activator (rt-PA), or sodium citrate with the
catheter locking solution.
 Sodium citrate 4% is as effective as UFH but may offer a
better safety profile at a reduced cost.
 HD lock solutions containing UFH and citrate was
associated with significantly fewer bleeding episodes.
 UFH 5,000 units/mL twice weekly and recombinant tissue
plasminogen activator (rt-PA) 1 mg per catheter lumen
once weekly were instilled in patients receiving HD. and
this significantly decreased catheter malfunction
compared to the patients receiving UFH only for catheter.

Infection
 blood cultures should be collected prior to the administration
of any antibiotics.
 AV fistula infection , give empiric broad-spectrum antibiotic
therapy, usually with vancomycin plus an aminoglycoside.
Antibiotic , if the infection is confirmed, should continue for a
total of 6 weeks and should be tailored to culture sensitivities.
 AVG require antibiotic therapy , and a surgical procedure to
remove the infected graft material.
 A suspected infection in a temporary catheter may warrant
catheter removal and a culture of the catheter tip should, if
possible.

Prevention
 minimizing the use and duration of catheters.
 proper disinfection and sterile technique, and the use of an
antimicrobial ointment at the exit site (mupirocin
2%, povidone-iodine).
 limit the manipulation of the catheter, utilize an antiseptic
wash (tincture of iodine, chlorhexidine, etc.) for skin
preparation.
 the use of face masks by the patient and caregiver, can
significantly reduce the incidence of catheter-related
bacteremia.
 Topical application of 2% mupirocin ointment to a tunneled
HD catheter exit site after each HD session can increase
infection-free days.

Note
Mupirocin prophylaxis may lead to the
development of methicillin-resistant S.
aureus(MRSA).
So ,
Alternative topical preparations to
mupirocin to combat potential MRSA
resistance are emerging and include
octenidine dihydrochloride body wash,
polyhexanide gel, and ethanol 70%
combined with natural oil emollients.

 A 6-year study that prospectively monitored HD
patient catheter infection rates with a once-a-week
application of a topical polysporin triple ointment
(bacitracin/gramicidin/polymyxin B) to CVC exit
sites did not reveal an increase in S.
aureus resistance.

 Peripheral blood draws are often avoided in HD patients
as an effort to protect potential or future HD vascular
access sites.
 Thus blood cultures are generally obtained from the
blood tubing connecting the catheter to the HD machine.
 A full-course of antimicrobial treatment is warranted if
these blood cultures are found to be positive.Empiric
therapy with coverage for both gram-positive and gram-
negative bacteria should be initiated after the blood
cultures are obtained.
 The incidence of MRSA bacteremia is high enough to
warrant initial treatment with vancomycin for gram-
positive coverage and either an aminoglycoside or third-
generation cephalosporin for gram-negative coverage.

 Antibiotic selection should be based on bacterial
coverage and the ability to optimize pharmacokinetics
by administering a dose after a HD treatment session
without requiring additional dosages between HD
sessions.
 In other words , antibiotic that are not be excreted with
hemodialysis , or antibitotic has a 1-2 days half life which
they should be excreted at the time with hemodialysis .
 Examples of antimicrobial agents that meet these
objectives are vancomycin, cefazolin, ceftazidime,
daptomycin, and aminoglycosides.

 the infected catheter should be removed if S.
aureus, Pseudomonas species, or Candida species are
identified as the infectious cause.
 Although removal of the catheter is warranted since up to
75% of patients have a recurrence of bacteremia after
completing a course of antibiotics, this is not always
possible and other options may need to be considered.
 Options such as replacing the catheter over a guidewire or
using a catheter lock solution in conjunction with IV
antibiotics have been suggested as an alternative.
 the catheters can be salvaged using catheter lock
solutions in addition to systemic antibiotics.

 the catheter lock solutions using, UFH 5,000 units/mL
and tetra sodium EDTA, found an increased rate of
microbial colonization with UFH.
 the tetra sodium EDTA solution had an increase rate of
thrombosis.
 An alternative to UFH and tetra sodium EDTA may be
4% sodium citrate to maintain catheter patency.
 A comparison of UFH 1,000 units/mL to the
combination solution of 4% sodium citrate
with gentamicin 320 mcg/mL (mg/L; 669 µmol/L) as a
catheter lock solution significantly reduced the incidence
of catheter related bloodstream infections.

Hemodialysis complications

In this document