Complications druing Hemodialysis

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Complications during Hemodialysis1v..vn 1[ 1v]], I)Nephrology DepartmentHHUMCCommon ComplicationsHypotension (20 - 30)Cramps (5 - 20)Nausea and Vomiting (5 - 15)Headache (5)Chest pain (2 - 5) Back pain (2 - 5), Itching (5)Fever and Chills (1)Hypotension It`s the most common acute complication oI HD. Incidence : 2050 . older patients and women more Irequent. Increased morbidity and mortality especially when episodes occur Irequently. ETIOLOGY Many Iactors may contribute to dialysis hypotension.These include: A rapid reduction in plasma osmolality Inaccurate determination oI true "dry weight'. Rapid Iluid removal in an attempt to attain "dry weight'. Autonomic neuropathy. Diminished cardiac reserve. Use oI acetate rather than bicarbonate as a dialysate buIIer. Intake oI antihypertensive medications that can impair cardiovascular stability. Use oI a lower |Na| in the dialysate. Sudden release oI adenosine during organ ischemia. Ingestion oI a meal immediately beIore or during dialysis. Arrhythmias or pericardial eIIusion with tamponade, which are volume-unresponsive causes oI hypotension. Reactions to the dialyzer membrane, which may cause wheezing and dyspnea as well as hypotension. Increased synthesis oI endogenous vasodilators, such as nitric oxide.Ultrafiltration UltrafiltrationOsmolalityOsmolality Fall FallWarmWarm Dialysate DialysateBio Bio- -incom incom- -patibility patibilityEndotoxin EndotoxinAcetate AcetateInfusion InfusionVolume VolumeVasopressors VasopressorsVasodilatator VasodilatatorCellCell Dysfunction DysfunctionComplement ComplementActivation.Activation. Cytokine release Cytokine releaseHypoxemia HypoxemiaHeart Disease Heart DiseaseVascularVascular Disease DiseaseAutonomicAutonomic Dysfunction DysfunctionHormonalHormonal Dysfunction DysfunctionMedications MedicationsSepsis SepsisInfection InfectionVasovagal stim. Vasovagal stim.HYPOTENSiON HYPOTENSiONCARDIAC CARDIACOUTPUT OUTPUTPERIPHERALPERIPHERAL RESISTANCE RESISTANCEPATHOGENE88MEDATOR8PATHOPHY8OLOGY PATENTDIAGNOSIS AND TREATMENT : !atients with hypotension may suIIer Irom light-headedness, muscle cramps, nausea, vomiting, and dyspnea. The acute management oI low blood pressure associated with hemodialysis includes the Iollowing: UF should either be stopped or the rate decreased The patient should be placed in the Trendelenburg position The blood Ilow rate should be reduced Intravascular volume may be replaced with mannitol or saline. Further treatment is based upon the etiology oI the hypotension. !articular concerns should include: Occult sepsis !reviously unrecognized cardiac and/or pericardial disease GI bleeding !revention: Accurate setting oI the "dry weight" Steady, constant UF Increased dialysate |Na| and Na modeling Sequential UF and isovolemic dialysis Bicarbonate dialysate buIIer Temperature control Improvement in CV perIormance Midodrine Avoidance oI Iood Adenosine release Recommendations Ior !reventionAmong patients with resistant cases oI intradialytic hypotension, the 2005 K/DOQI guidelines suggest the use oI the Iollowing combinations oI modalities:Midodrine and dialysate temperature proIiling Dialysate temperature proIiling plus 3 meq/L dialysate calcium level Dialysate temperature and sodium modeling Isolated UF and other approaches may also provide beneIit.Muscle cramps Etiology: The 4 most important predisposing Iactors are : Hypotension Hypovolemia High UFR Use oI low-sodium dialysis solution. These Iactors all tend to Iavor vasoconstriction. Muscle cramps most commonly occur in association with hypotension, although cramps oIten persist aIter seemingly adequate B! has been restored. Contributing factors: levations in C!K levels. Hypomagnesemia. Hypocalcemia !redialysis hypokalemiaMuscle crampsManagement : Hypotension muscle cramps0.9 saline. Hypertonic solutions (saline, glucose, mannitol) may be more eIIective in dilating muscle-bed blood vessels. Hypertonic glucose administration is preIerred Ior treatment oI cramps in nondiabetic patients . NiIedipine (10 mg) has also been Iound to reverse cramping (should be reserved Ior cramping in hemodynamically stable patients). Forced stretching oI the muscle involved may provide relieI.Nausea and Vomiting Incidence : 10 The cause is multiIactorial : Most episodes in stable patients are probably related to hypotension. Disequilibrium Syndrome Dialyzer Reactions. Gastroparesis Contaminated or incorrectly Iormulated dialysis solution (high sodium, calcium) Management : The Iirst step is to treat any associated hypotension. Vomiting may be particularly problematic when associated with a hypotension-induced reduction in the level oI consciousness due to the risk oI aspiration. Antiemetics can be administered Ior other causes oI vomiting as needed. Prevention : Avoidance oI hypotension during dialysis is oI prime importance. !ersistent symptoms unrelated to hemodynamics may beneIit Irom metoclopramide. Sometimes a single predialysis dose oI 5 -10 mg is suIIicient.Headache Etiology : Cause is largely unknown. May be a subtle maniIestation oI the disequilibrium syndrome. CaIIeine Withdrawal. With atypical or particularly severe headache, a neurologic cause (particularly a bleeding event precipitated by anticoagulation) should be considered. Mg deIicient Management : Acetaminophen can be given during dialysis. Prevention : Decreasing dialysis solution sodium also may be helpIul in patients being treated with high sodium levels. A cup oI strong coIIee may help prevent (or treat) caIIeine withdrawal symptoms. A cautious trial oI magnesium supplementation may be indicatedChest pain and Back pain Incidence :1 to 4. The cause is unknown. There is no speciIic management or prevention strategy, though switching to a diIIerent variety oI dialyzer membrane may be oI beneIit. The occurrence oI Angina during dialysis is common and must be considered in the diIIerential diagnosis, along with numerous other potential causes oI chest pain (e.g., hemolysis, air embolism, pericarditis). II dialysis is continued, the administration oI O2, reduction oI the desired UF and/or blood pump speed, and administration oI nitrates or MO should be considered on an individual basis.Itching It`s a common problem in dialysis patients. tiology : ? May be a maniIestation oI low-grade hypersensitivity to dialyzer or blood circuit components. Itching may simply be present chronically. Viral (or drug-induced) hepatitis should not be overlooked as a potential cause oI such itching. Management : Standard symptomatic treatment using antihistamines is useIul. Chronically, general moisturizing and lubrication oI the skin using emollients is recommended. Ultraviolet light therapy may be oI help Recent small, randomized studies have suggested beneIicial eIIects Ior ,-,50393 !ruritus oIten is Iound in patients with elevated serum calcium - phosphorus product and/or substantially elevated parathyroid hormone (!TH) level.Dialysis disequilibrium syndrome The dialysis disequilibrium syndrome (DDS) is a central nervous system disorder described in dialysis patients. It is characterized by neurologic symptoms oI varying severity that are thought to be due primarily to cerebral edema. New patients iust being started on hemodialysis are at greatest risk, particularly iI the BUN is markedly elevated (above 175 mg/dl) Other predisposing Iactors include : Severe metabolic acidosis Older age !ediatric patients The presence oI other CNS disease such as a preexisting seizure disorder.Dialysis disequilibrium syndrome Pathogenesis : The symptoms oI DDS are caused by water movement into the brain, leading to cerebral edema. Two theories have been proposed to explain why this occurs: a reverse osmotic shiIt induced by urea removal; and a Iall in cerebral intracellular pH.Clinical Manifestations: arly : headache, nausea, disorientation, restlessness, blurred vision, and asterixis. More severely aIIected patients progress to conIusion, seizures, coma, and even death.Dialysis disequilibrium syndrome Management: In an acute dialysis setting: One should not prescribe an overly aggressive treatment session. The target reduction in the BUN should initially be limited to about 40. Use oI a low-sodium dialysis solution dialysis solution (more than 2 - 3 mM less than the plasma sodium level) may exacerbate cerebral edema and should be avoided. In hypernatremic patients, one should not attempt to correct the plasma sodium concentration and the uremia at the same time. It is saIest to dialyze a hypernatremic patient initially with a dialysis solution sodium value close to the plasma level and then to correct the hypernatremia slowly postdialysis by administering 5 dextrose. Daily dialysis Ior 3 to 4 days with gradual increases in dialysis time and blood Ilow oIten prevents symptoms and signs oI disequilibrium. For severe headache, seizures, or obtundation, the dialysis procedure should be immediately terminated. Intravenous administration oI mannitol or diazepam is useIul in treating seizures caused by disequilibrium. Arrhythmia: Risk Iactors include: CAD, advanced age, myocardial dysIunction, and LVH During hemodialysis, the incidence oI arrhythmias may be enhanced because oI rapid Iluctuations in hemodynamics and electrolyte concentrations, as well as the induction oI hypoxemia in patients with a high incidence oI myocardial disease. Cardiac Tamponade: Unexpected or recurrent hypotension during dialysis can be a sign oI pericardial eIIusion or impending cardiac tamponade. Intracranial Bleeding: Underlying vascular disease and hypertension combined with heparin administration can sometimes result in the occurrence oI intracranial, subarachnoid, or subdural bleeding during the dialysis session. Seizures: Children, patients with high predialysis plasma urea nitrogen levels, and patients with severe hypertension are the most susceptible to seizures during dialysis. Seizure activity can be one maniIest